Hi Christine - the answers as you know are really complex but I think it boils down to group and individual psychology. It takes a lot of ego strength and courage to wear a mask these days, as that tribe is dwindling and few like to be an outsider. People want (need?) the pandemic narrative to be over, as the experience was just so painful, so some of the hostility directed towards people wearing masks comes from a subconscious enforcement of the story arc that brings us back to "normal." Instead of being cast as an act of simultaneous altruism and self-protection, masking for most people is now a faux pas or downright assault on the social contract wherein we build trust by swapping germs (see handshakes, hugs and kisses). I get it, masking sucks. But I do it anyway in the office, and with the older or sicker population that makes up the majority of our patients, it seems like the right thing for a health care worker to do. But I'm not forcing anyone to do anything, and more patients look at me funny than thank me, so there's that!
Your monthly Covidlandia reports are terrific, and the take-home points incredibly helpful. Very sad to learn how many children are suffering long covid. We have really failed our kids on this one. The ventilation/acid-based air was intriguing—there are so many benefits to good ventilation, and here is another!
Re the Hawaii stats, yet more confirmation of your point sometime back that it’s good to check what’s going on locally, as well as regionally and nationally. On that score, “interesting” to see that in New York, New York City has far worse stats than the rest of the state.
In “local” news: unfortunately, there is still no NYC data showing on the CDC site—I will be writing a follow-up to the city health department, as I thought that should have been happening by now. It’s important for many reasons, one of which is the CDC site is much better, eg, at showing trends. Also, a la what you note about Hawaii, an “outlier” state can affect the stats for a whole region, so it’s important to be able to tease that out. For NYC—and I think this would remain true if NYC were reporting data to the CDC?—I do not rely on regional reporting, as it appears that NYC is typically an outlier there, and not in a good way.
There is so much to take into account, it’s not surprising so many just give up. But this is why your reports are so invaluable. You are definitely in the Jetelina mold of clear, well-informed, reporting. Thank you so much!
Since you follow the data very closely, perhaps you can tell me how to find the Covid death reports that are now only based on national reporting (from states with certified death, as I understand it) and which do lag a lot behind what is currently happening? I did find it once or twice. The first time it was displayed as a graph on which you could hove and it would pull up a weekly date and the death number. That was very easy to work with. The next time I got a chart/table which had confusing headings and was harder to follow. Now I can't find it at all.
Hi DM - like you I used to watch these death counts on a granular level early in the pandemic to get a sense of how bad each area of the country/world was becoming, and to get a sense of what was coming down the pike in terms of new variants and severity of illness. Now I just hear the weekly death count and have become slightly more numb to it, though I will never accept it as OK. The NYT used to have a good running tabulation. I guess I would check these resources at CDC, even though health systems are no longer required to report on Covid hospitalizations as of 5/1/2024:
Hi Susan, and I'm so happy that you found good stuff as promised in this episode. I admit that I spent most of the day Sunday writing it... takes longer than I anticipate, always!
You are going to be tired of me thanking you for your efforts re: NYC data collection and reporting, but I'll say it anyway: Thank you! Please don't feel like you have to constantly pour your precious time into this, but when you do it is a noble effort for sure. I think of NYC as a city state, like most world class cities, and you are correct that it is often a canary in the coal mine before regional trends.
I used to take a train from Rutgers to The Village on some random days while in college. I really miss McSorley's Olde Ale House, The Strand Bookstore, and just meandering around. Will add that to the short list of day trips I need to do from Philly, soon.
The Strand bookstore - what a great memory! And I thank you for your updates and intelligent analyses of the studies that are done and their implications.
Your encouragement means so much! And rest assured, it is well worth it to me to spend some time on the NYC situation—it’s not a huge deal, nothing like the time YOU spend AND all the good you do in the world as a PCP and generally—and among other things, it is in my self-interest! Those are great NYC landmarks you noted, and of course meandering around is a great pastime here (as is true for Philly)!
Thank you!! Enjoying my corner of Covidlandia where windows are open and outdoor dining is easy. I really hope that Ensitrelvir is approved--it would mean no monopoly, another effective option that doesn't appear to have the same drug/drug interactions and hopefully less expensive. I also think that lowering viral load is worthwhile.
I mask in medical facilities, good "return on investment"--masking is "social poison" as you've mentioned in the past, but masking strategically is so worthwhile. As my ID trained PCP says, behind her mask: "it's so nice not to have respiratory illness."
Please keep sharing the gorgeous watercolors by your talented teenage daughter!
100% agree with having ensitrelvir for those options, and while I am not conspiracy-minded by nature, it does make you wonder why the FDA has been so slow to approve this medicine already available in many countries (including Japan, of course). One could speculate American pharm company Pfizer stands to lose a lot of prescriptions... but I'm not going to bother speculating beyond that b/c I'm grateful for all the hard work FDA does to keep us safe with an ever-threatened budget.
I salute your courage and wisdom re: masking, and I also enjoy not being sick much. Like you I'm sure, I used to get sick at least 5-6 times per year, often from patients no doubt. Now it's more like I've been sick twice in 4 years.
Compliment to my daughter read to her beaming smile, thanks!!
Fascinating about the more acidic air and Covid! Thanks for the monthly report. As my teen’s new, masked pediatrician agreed with me: “we like not being sick.” The new teen in your house is so clearly talented in a difficult medium—watercolor, right? Thanks to her for sharing that, it’s so good!
Thanks Donna! I had to use Claude.ai and then google to patch together this W.C. Fields quote that came to mind but I lacked the synapses to fully recall it:
"Never share a stage with children or animals."
Lots of meanings there, but I will gladly keep sharing the little stage here for her art whenever she wants to contribute, even if she upstages me that's great ;)
Glad you share a fascination with the acidic air study... it makes me think of how infinitely complex all the little phenomena are that occur on microscopic and nano-scales that end up producing our world experience!
Nice work on this summary and well laid out. Let's face it, COVID is the new normal. A couple of notes.
Mentioning the sharp rise the pacific , recalled mentioning this a couple of weeks ago. Think this helps to support another potential source of the FLiRT siblings.
"Singapore's health ministry recently announced that its closely monitoring a recent rise in COVID-19 infections, noting cases were up sharply for the week ending May 11, with a rise in hospitalizations, but intensive care unit (ICU) admissions remaining low." https://www.moh.gov.sg/news-highlights/details/update-on-covid-19-situation
Disappointed about ensitrelvir, FDA is still stuck on symptoms rather than reduction in severity. Same endpoint one used for Flu and maybe it time to reevaluate this 'endpoint'. It made me rethink the about antivirals for Influenza. After all, a severe respiratory disease damage the lungs and the body is still doing cleanup.
Think the committee will be meeting soon on the vaccine and and likelihood it will be the FLiRT siblings.
Hi KB - and thanks for sharing this link to the Singapore Ministry of Health. A few very interesting quotes from there:
1) "Even as we live with COVID-19 as an endemic disease, we cannot afford to lower our guard. To date, about 80% of the local population have completed their initial or additional dose but have not received a dose within the last year."
Similar public disinterest in staying up to date?
2) "The protection against COVID-19 outweighs the risk from COVID-19 vaccination, and we urge individuals to keep updated with their COVID-19 vaccination. Those who are at greatest risk of severe disease, including individuals aged 60 years and above, medically vulnerable individuals and residents of aged care facilities, are recommended to receive an additional dose of the COVID-19 vaccine for 2024, around one year (and not earlier than five months) after the last dose received.... In addition, all vaccinated individuals aged six months and above are encouraged to receive an additional dose of the COVID-19 vaccine for 2024 as well."
Fairly similar to U.S.
3) "The updated COVID-19 vaccines continue to be free for all eligible residents. Leveraging the trusted relationship between our family doctors and patients."
That's what I'm talking about, Singapore!
And I like your updated vaccine bracket with FLiRT for the win, too!
I'm curious what your take on using metformin during a Covid infection is? There's good data from recent studies about its ability to decrease viral load and reduce the risk of rebound symptoms if given early in an infection. The latest study was published May 1, 2024 in Clinical Infectious Diseases. It is titled, "Favorable Antiviral Effect of Metformin on Severe Acute Respiratory Syndrome Coronavirus 2 Viral Load in Randomized, Placebo Controlled Clinical Trial of Coronavirus Disease 2019."
Hi Tara and thanks for stopping by! This question is great. I plan to try metformin when I get Covid, and if tolerable with GI side effects, finish the course that was used in the study you linked to. I've prescribed it to a few patients with good results, although many more are skeptical and barely agree to take Paxlovid. My "Covidlandia" bit from last month does directly address this, with some links back to previous posts I've done, so please feel free to take a deep dive on the nuances here. I'll post the link, and then cut and paste the relevant text, though you'll have to follow the URL below to be able to click on the relevant hyperlinks:
"Another vote of confidence in metformin to prevent long Covid
This is really big news, again.
A 42% reduction in long Covid rates for those average risk patients treated with oral metformin. That’s huge for a disease that is a slowly moving, mass disabling event for millions of people.
Here’s exactly what the study showed in addition to reducing long Covid rates:
In the COVID-OUT randomized trial for outpatient COVID-19, metformin reduced the odds of hospitalizations/death through 28 days by 58%, of emergency department visits/hospitalizations/death through 14 days by 42%, and of long COVID through 10 months by 42%.
Despite headlines this week trumpeting the news, and respected doctors like Paul Sax, MD writing mainstream commentaries, this data is not new. In fact, I’ve been writing about this good quality, randomized, placebo-controlled clinical trial called COVID-OUT for over a year now. For example:
my article entitled “How to prevent long Covid” from March, 2023
my article entitled “My self-treatment plan for Covid” from January, 2024
I shared this stuff on some doctor sites and mostly I got skeptical or even cynical feedback. Doctors (and people in general) can be really resistant to change and new ideas that are not obvious and accepted by the herd. I’ve had very few patients take me up on the offer to try metformin, as many have heard Covid is just a cold now.
It often is not.
So why is metformin finally poised to become a more mainstream treatment for Covid? I suppose it’s because this further data from the COVID-OUT trial published this week in Clinical Infectious Diseases really focused on a mechanism of action. Metformin reduced viral loads in the body by 3.6-fold.
Paxlovid also reduces viral loads by up to 90%, by the way, and I’ve written about how it has been discarded prematurely by many thought leaders as well. But I digress. Back to metformin.
Beyond the viral load reduction as a mechanism, metformin has other effects that were not measured in this trial. I’ll quote my previous article:
Metformin has some plausible mechanisms for why it might help reduce long Covid, including immunomodulatory effects, complement system protective effects, blunting damage of dopaminergic neurons, and mitochondrial protective effects.
So bottom line here is that long Covid is what I fear the most for myself and my patients… not so much hospitalization and death anymore. I also fear cumulative damage that goes undetected and shows up later, unofficially counted by ever-increasing excess mortality in the world; Covid has probably claimed 30 million precious lives. When people ask me for advice I’ll err on the side of aggressive treatment."
Hope this helps and provides some validation for your astute question.
Thanks for your post.All your posts help me stay healthier and communicate with my pcp better.
We just got back from Hawaii (Big Island). I was wondering why I was seeing a higher incidence of masking in grocery stores (below 5%, but noticeable). At least a few "essential workers" were staying on top of things.
We saw zero masks on the flights back to Houston, where we noticed a large collection of unclaimed suitcases roped off in the baggage claim area, likely belonging to still-quarantined passengers who came on a United flight from Vancouver earlier that night. Ironically, I had masks with me, but failed to check local trends and use any. Sigh. Staying aware and proactive takes more work.
Your comments on the benefits of good ventilation are likewise relevant to us residents of over-air-conditioned Houston. Open ventilation practices here increase our AC bill. Masking here is perceived as a political statement. For instance, when I voted in the 2022 primaries, I decided to participate in the Republican polls to support those rare specimens that weren't spouting anti-vax, anti-mask, anti-Fauci tirades on their websites, so that if a Republican wins a specific post, they'd be less likely to be irrational. Standing in line to vote, I was the only masked person in the group. Almost all those waiting in the Democratic line were masked. One well-meaning lady turned to me and told me that the Democrat line was "over there" (pronounced "ova they-ah".) She had trouble processing my response that I was where I meant to be.
Jerry this is so fascinating! I'll keep my fingers crossed that the trip to Hawaii did not bring any unintended souvenirs back home for you. Would absolutely love to visit someday, I've never been. We have a long flight coming up and I plan to wear an N95, which really sucks, but has not failed me yet. People definitely resent you when you intrude upon the group narrative that "it's all good now." But in Philly (80% Democratic) there is a live and let live vibe so although masking rates are really low (and that's OK for people to decide, I'm not commanding anyone!) at least no one has told me at the airport in a Philly accent: "Yo, why are youse guys masking?"
I would happily welcome the kind of Republican you are talking about, we need many more of them to stand up to the shamefulness and reclaim the better parts of their grand old party. Ok sorry for the politics, I'll head over to HCR for that ;)
Some data out claims that getting the Pneumovax immunization can also decrease our chances of contracting Covid. Any thoughts on that? Also, what a beautiful painting, please compliment your artist for me!
Hi Nurjam :) I'm impressed you caught this study, too!
I wrote a little post about this back in March in case you want a deeper dive, here is the link and a quick quotation. And your compliments shared with daughter who is getting an artistic confidence boost from this, so thanks!
"So here is the bottom line from the systematic review of 16 prior studies, just published last week in the Journal of Infectious Diseases:
In children, data from 4 studies showed that Prevnar cut influenza rates by 41% to 86%. That’s comparable to a flu shot.
In children, infection rates with other viruses, including coronaviruses, parainfluenza, and human metapneumovirus were also significantly lower.
In adults, Prevnar reduced serious lower respiratory infections caused by several common viruses by 4% to 25%.
In adults, Covid outcomes like diagnosis rates, hospitalizations, and deaths in the hospital were all reduced by 33%. These results were before Covid vaccines were available.
In adults, lower respiratory infections like bronchitis and pneumonia caused by influenza A were up to 13% to 36% lower."
A recent study found them to not be anywhere near as effective as N95s. I think people do not wear them properly. "Relative efficacy of masks and respirators as source control for viral aerosol shedding from people infected with SARS-CoV-2: a controlled human exhaled breath aerosol experimental study" Lancet May 29, 2024.
I do not know enough about the study to discount. I have not read the whole study *yet* but other studies have been more positive about the KN95. I would just defer to my N95 when I am any place that is crowded or I am not moving: any theater, airplane, public transport. I personally can't risk another infection.
Well answered by Donna below, I'll thank her for that. Publicly available masks run on a continuum of effectiveness, from crummy gators to great N95s. KN95s are very good, but the seal on the face is the variable. Viral dose matters, so duration and intensity of exposures matter in terms of how well a mask will hold up.
Like Donna said, I too wear an N95 on planes, and have personally checked the CO2 ppm while flying and can confirm the ventilation is not adequate (usually hovering around 1500 ppm on flights I've taken). I like 3M Aura.
I never mask outside anymore, and inside depends on prevalent Covid rates and how tight people are packed in, and how long I'm going to be in there. Once again, to each their own, and a lot depends on how high risk we are, and personal risk tolerance!
I think cases are slowly rising here in the PNW. Good friend of mine got it from her roommate (who would not test until it was too late to effectively isolate). I find the the info about CO2 to be fascinating. Pretty sure I picked up my recent case from a poorly ventilated breakfast room in a hotel. I am still kicking myself over it. I am 4 weeks post-acute Covid and I am only now feeling close to normal. Still coughing and my 67 year old brain may never be the same. I will continue to mask in almost all places I go. Just an FYI: Paxlovid can be hard to get. Pharmacies stock very little. I got the last dose at a local Walgreens and my friend with Covid had to check 6-7 before she found it.
Hi Donna - thanks for you other comments here. Good to know about the decreased availability of Paxlovid in your area. Yikes. I wonder if that is a combination of low stocking and increased demand like you are describing in the PNW? Will keep this in mind and on the radar! And no shame in the most recent Covid case. We have to live and take chances. It is getting harder and harder to maintain relationships while playing the Covid game the way we know works. Nonetheless I appreciate your story here, and sincerely hope for your full recovery. I just learned that a close friend who is 50 has been suffering from pretty severe long Covid for over a year now (chest pain and PEM), despite being up to date on vaccines and otherwise healthy. Has some joint hyper mobility at baseline (a risk factor for LC) and did not take antivirals. Not sure they would have helped her individually, but I know you try to leave it all on the field while battling. Again, wishing you well :)
Another well-written, well researched, and thoughtful report. Thank you for keeping us on our toes and keeping caution in the forefront of our minds. We'll certainly be on the lookout for well-ventilated areas and we'll be outside as much as possible over the summer months. You have a very talented daughter. Maybe think about making some prints of her work and selling them or swapping them for some donations to charitable causes.
Hi Mike! Thank you for reading and for your support! I know the constant drone of caution can be annoying at best and insufferable at worst, but I'll keep preaching as long as Covid is still a thing and hoping not to offend people. I think that's part of my job in primary care... no one really likes to hear me drone on about colonoscopies either!
And I think your idea regarding making prints is a great one, we would like to instill a little hustle, entrepreneurism, and charity... many thanks and will extend your compliments to her asap ;)
Personally your monthly COVID updates don’t offend— it’s the polar opposite. As the powerful need to deny COVID is so pervasive, I find Covidlandia a wonderful reality check. Yes, thankfully we can move on a bit, but it’s endemic and as Singapore said— don’t let down your guard. Navigating endemic requires nuance and willingness to be an outlier and your kind, thoughtful, calm updates are incredibly helpful. Please don’t stop.
Just read a great article from STAT on the CO2=less acidic=much longer time to degrade active virus--you'd covered this but it's just so important. I use a CO2 meter but just thought it showed good ventilation. Now I understand that poor ventilation is a petrie dish
And here is a claude.ai digestion of that really technical article I referenced above. The chemistry is tricky but the end result easy to understand (poor ventilation favors viruses in multiple ways):
This article investigates how the pH, alkalinity, and acidity of respiratory aerosols affect the stability and transmission of SARS-CoV-2, the virus that causes COVID-19. The key findings are:
Respiratory aerosols become highly alkaline (pH > 10) after generation due to the evaporation of bicarbonate ions, which increases the pH.
The high alkalinity of respiratory aerosols is a significant factor in reducing the infectivity of SARS-CoV-2 over time.
Increasing the concentration of carbon dioxide (CO2) in the air limits the increase in pH of respiratory aerosols, thereby improving the aerostability (ability to remain infectious in aerosol form) of SARS-CoV-2.
Even moderate increases in CO2 concentration (e.g., from 500 ppm to 800 ppm) significantly improve the aerostability of SARS-CoV-2 variants, including the Delta and Omicron variants.
The improved aerostability of SARS-CoV-2 at higher CO2 concentrations is predicted to increase the overall risk of COVID-19 transmission, especially in poorly ventilated indoor environments.
The authors propose that the seasonal variation in indoor CO2 levels may contribute to the seasonality of respiratory viral infections, in addition to the effects of relative humidity.
In summary, the study highlights the critical importance of ventilation and maintaining low CO2 concentrations in indoor environments to mitigate COVID-19 transmission by limiting the aerostability of SARS-CoV-2, which is affected by the pH and alkalinity of respiratory aerosols.
Thanks for a good update . Many of my patients roll their eyes as I explain about some detail about Covid I heard on TWIV podcasts. They are like most of the country in wanting to be done with Covid. Fun to see someone else who nerds out on Covid , chemistry and study analysis. And I cannot help but think that the primary care perspective is so unique - we see the range from “ it’s a cold “ to Looooonnnnnnggggg Covid . Not to mention post Covid vascular / pulmonary /whatever damage. I get why many of my patients are a bit mystified - after all no one they know has any real trouble from Covid ( except the damn government rules that were imposed of course) . Stay well .
Such good commentary and I live this every day with you! I think Vincent on TWiV, though he does a great job overall, is a bit of a minimizer at the same time actually. if I were Daniel Griffin, I would be constantly redirecting him away from some pretty wrong commentary. For example, on the June 1 episode I just listened to, he is only just now realizing that ventilation on planes is not what they say it is, and questioning whether kids with brain fog are making it up. In this episode of Covidlandia, for example kids who are complaining of fatigue and cardiovascular symptoms, 90% have objective evidence of that, why wouldn’t it be the same with cognitive. Let’s just keep gaslighting kids and women? Anyway, hang in there I’ll keep the nerdy updates coming!
Yes Vincent can be like that . It was a bit ironic when he declared he was done with the Covid vax after 3 . I think he might have later changed his mind and done a 4th . I do want to see Daniel push Vincent a little bit more at times. Daniel is so very gracious and appreciates the spot V gives him. I do note how Daniel brings up Michael Osterholm and CIDRAP from time to time . CIDRAP seems to hold a broader view than Vincent vis a vis Covid . And I wonder - will Lex Fridman have Vincent back for a Covid “review “ ?
Hi Ryan, and thanks again for a wonderful update, and the shoutout! Can confirm that it's a s#!+show here in Australia, to the extent that they cancelled all except urgent elective surgery in the public system in the state I'm in. There were 240 clinical staff off sick the public system statewide the previous week, and they finally "recommended" masks for staff but still didn't mandate it! Still, masking rates went from perhaps 2% to maybe 40%, but that was before I tested positive so don't know what's happening now! I've been consistently wearing N95 at work but had been a bit slack at supermarkets/tram/train if not too crowded, and had a mild but prolonged non-Covid cold a few weeks ago. Spouse who is a GP says this is the worse winter for respiratory infections she's ever seen in all her years of primary care (since 2016). Lots of flu, RSV, mycoplasma, Covid, sometimes in combination! And the kids she's seeing are really sick and there is apparently a shortage of azithromycin. Raises interesting points about vaccination for one respiratory ailment being protective against others. Sadly my family in Singapore don't seem to have very proactive primary care and are waiting for their primary care to ask them to get vaccinated before going despite me nagging them to get vaccinated!
I got tested the evening after I got symptoms, probably due to complacency, and literally exclaimed "oh shit" and ran into the spare bedroom and put a mask on. Kids got vaccinated in February (not recommended in Australia but happily we insisted and the primary care doctor at saw acquiesced. Spouse caught it January so hopefully still immune. Anyway, day 5 for me now and family still not symptomatic. I started Paxlovid and Metformin that evening and could almost feel the Paxlovid kick in (wasn't terrible to start with, but felt basically normal after the 3rd dose) but still tire easily. Also yucky Paxlovid mouth but I'll cope with that! Thanks for the reminder about adequate ventilation, but it feels like banging head against the wall trying to get traction with schools etc. Kids' (public) school just spent $3 million for a "kiss and drop" built within 3 months, but not a cent allocated to air filters despite over a year of us asking for it.
Anyway, sorry for the long post, but thanks again for the update! Hope you and your readers keep well!
Zhong, thank you for the generosity of your time posting this comment and status report! Here’s to your speedy and complete recovery. I know the Paxlovid taste, metallic and bitter to me. Please let me know if you stomach the entire metformin titration upwards (I think week 2 is 500mg qam, 1,000 qpm). Most folks don’t bother trying it here, but among the few for whom I have prescribed this for, I would say about 50% stick with it, the rest feel too crummy with GI stuff like nausea.
The cancellations of non urgent surgeries, and the implicit staffing shortages Australians must be dealing with make me shudder… those kinds of meltdowns affect everything from surgery to ER to primary care and have collateral detrimental effects on health outcomes overall. Not your fault at all!
We are traveling this week and doing a lot of museums (masked but Enro quality) and even some indoor restaurants unmasked when the weather cool and rainy like today, so I may be joining you soon 😔
N95 on plane and thinking I’ll try switch back over to that tomorrow as the last museum was horribly packed and ventilated.
Just can’t play this thing perfectly and still have a family and friends.
Once again wishing you well, and I won’t comment on everything you’ve stated here except that it’s been bet enlightening. Take care!
Masking is a great idea & a small annoyance. Why is it that most medical offices suggests masks BUT most of the staff do not wear them? Very confusing
Hi Christine - the answers as you know are really complex but I think it boils down to group and individual psychology. It takes a lot of ego strength and courage to wear a mask these days, as that tribe is dwindling and few like to be an outsider. People want (need?) the pandemic narrative to be over, as the experience was just so painful, so some of the hostility directed towards people wearing masks comes from a subconscious enforcement of the story arc that brings us back to "normal." Instead of being cast as an act of simultaneous altruism and self-protection, masking for most people is now a faux pas or downright assault on the social contract wherein we build trust by swapping germs (see handshakes, hugs and kisses). I get it, masking sucks. But I do it anyway in the office, and with the older or sicker population that makes up the majority of our patients, it seems like the right thing for a health care worker to do. But I'm not forcing anyone to do anything, and more patients look at me funny than thank me, so there's that!
What do you think?
Your monthly Covidlandia reports are terrific, and the take-home points incredibly helpful. Very sad to learn how many children are suffering long covid. We have really failed our kids on this one. The ventilation/acid-based air was intriguing—there are so many benefits to good ventilation, and here is another!
Re the Hawaii stats, yet more confirmation of your point sometime back that it’s good to check what’s going on locally, as well as regionally and nationally. On that score, “interesting” to see that in New York, New York City has far worse stats than the rest of the state.
In “local” news: unfortunately, there is still no NYC data showing on the CDC site—I will be writing a follow-up to the city health department, as I thought that should have been happening by now. It’s important for many reasons, one of which is the CDC site is much better, eg, at showing trends. Also, a la what you note about Hawaii, an “outlier” state can affect the stats for a whole region, so it’s important to be able to tease that out. For NYC—and I think this would remain true if NYC were reporting data to the CDC?—I do not rely on regional reporting, as it appears that NYC is typically an outlier there, and not in a good way.
There is so much to take into account, it’s not surprising so many just give up. But this is why your reports are so invaluable. You are definitely in the Jetelina mold of clear, well-informed, reporting. Thank you so much!
Since you follow the data very closely, perhaps you can tell me how to find the Covid death reports that are now only based on national reporting (from states with certified death, as I understand it) and which do lag a lot behind what is currently happening? I did find it once or twice. The first time it was displayed as a graph on which you could hove and it would pull up a weekly date and the death number. That was very easy to work with. The next time I got a chart/table which had confusing headings and was harder to follow. Now I can't find it at all.
Ah, wish I could assist, but I have only been following wastewater, so I am actually behind you in keeping up with data!
Hi DM - like you I used to watch these death counts on a granular level early in the pandemic to get a sense of how bad each area of the country/world was becoming, and to get a sense of what was coming down the pike in terms of new variants and severity of illness. Now I just hear the weekly death count and have become slightly more numb to it, though I will never accept it as OK. The NYT used to have a good running tabulation. I guess I would check these resources at CDC, even though health systems are no longer required to report on Covid hospitalizations as of 5/1/2024:
https://www.cdc.gov/nchs/nvss/covid-19.htm
Hi Susan, and I'm so happy that you found good stuff as promised in this episode. I admit that I spent most of the day Sunday writing it... takes longer than I anticipate, always!
You are going to be tired of me thanking you for your efforts re: NYC data collection and reporting, but I'll say it anyway: Thank you! Please don't feel like you have to constantly pour your precious time into this, but when you do it is a noble effort for sure. I think of NYC as a city state, like most world class cities, and you are correct that it is often a canary in the coal mine before regional trends.
I used to take a train from Rutgers to The Village on some random days while in college. I really miss McSorley's Olde Ale House, The Strand Bookstore, and just meandering around. Will add that to the short list of day trips I need to do from Philly, soon.
And Jetelina is a rock star!
The Strand bookstore - what a great memory! And I thank you for your updates and intelligent analyses of the studies that are done and their implications.
Your encouragement means so much! And rest assured, it is well worth it to me to spend some time on the NYC situation—it’s not a huge deal, nothing like the time YOU spend AND all the good you do in the world as a PCP and generally—and among other things, it is in my self-interest! Those are great NYC landmarks you noted, and of course meandering around is a great pastime here (as is true for Philly)!
Thank you!! Enjoying my corner of Covidlandia where windows are open and outdoor dining is easy. I really hope that Ensitrelvir is approved--it would mean no monopoly, another effective option that doesn't appear to have the same drug/drug interactions and hopefully less expensive. I also think that lowering viral load is worthwhile.
I mask in medical facilities, good "return on investment"--masking is "social poison" as you've mentioned in the past, but masking strategically is so worthwhile. As my ID trained PCP says, behind her mask: "it's so nice not to have respiratory illness."
Please keep sharing the gorgeous watercolors by your talented teenage daughter!
100% agree with having ensitrelvir for those options, and while I am not conspiracy-minded by nature, it does make you wonder why the FDA has been so slow to approve this medicine already available in many countries (including Japan, of course). One could speculate American pharm company Pfizer stands to lose a lot of prescriptions... but I'm not going to bother speculating beyond that b/c I'm grateful for all the hard work FDA does to keep us safe with an ever-threatened budget.
I salute your courage and wisdom re: masking, and I also enjoy not being sick much. Like you I'm sure, I used to get sick at least 5-6 times per year, often from patients no doubt. Now it's more like I've been sick twice in 4 years.
Compliment to my daughter read to her beaming smile, thanks!!
Fascinating about the more acidic air and Covid! Thanks for the monthly report. As my teen’s new, masked pediatrician agreed with me: “we like not being sick.” The new teen in your house is so clearly talented in a difficult medium—watercolor, right? Thanks to her for sharing that, it’s so good!
Oh! Meant to mention that watercolor, too. So talented in such a hard medium!
Thanks Donna! I had to use Claude.ai and then google to patch together this W.C. Fields quote that came to mind but I lacked the synapses to fully recall it:
"Never share a stage with children or animals."
Lots of meanings there, but I will gladly keep sharing the little stage here for her art whenever she wants to contribute, even if she upstages me that's great ;)
Glad you share a fascination with the acidic air study... it makes me think of how infinitely complex all the little phenomena are that occur on microscopic and nano-scales that end up producing our world experience!
Nice work on this summary and well laid out. Let's face it, COVID is the new normal. A couple of notes.
Mentioning the sharp rise the pacific , recalled mentioning this a couple of weeks ago. Think this helps to support another potential source of the FLiRT siblings.
"Singapore's health ministry recently announced that its closely monitoring a recent rise in COVID-19 infections, noting cases were up sharply for the week ending May 11, with a rise in hospitalizations, but intensive care unit (ICU) admissions remaining low." https://www.moh.gov.sg/news-highlights/details/update-on-covid-19-situation
Disappointed about ensitrelvir, FDA is still stuck on symptoms rather than reduction in severity. Same endpoint one used for Flu and maybe it time to reevaluate this 'endpoint'. It made me rethink the about antivirals for Influenza. After all, a severe respiratory disease damage the lungs and the body is still doing cleanup.
Think the committee will be meeting soon on the vaccine and and likelihood it will be the FLiRT siblings.
Looking forward to the next Covidlandia!
Hi KB - and thanks for sharing this link to the Singapore Ministry of Health. A few very interesting quotes from there:
1) "Even as we live with COVID-19 as an endemic disease, we cannot afford to lower our guard. To date, about 80% of the local population have completed their initial or additional dose but have not received a dose within the last year."
Similar public disinterest in staying up to date?
2) "The protection against COVID-19 outweighs the risk from COVID-19 vaccination, and we urge individuals to keep updated with their COVID-19 vaccination. Those who are at greatest risk of severe disease, including individuals aged 60 years and above, medically vulnerable individuals and residents of aged care facilities, are recommended to receive an additional dose of the COVID-19 vaccine for 2024, around one year (and not earlier than five months) after the last dose received.... In addition, all vaccinated individuals aged six months and above are encouraged to receive an additional dose of the COVID-19 vaccine for 2024 as well."
Fairly similar to U.S.
3) "The updated COVID-19 vaccines continue to be free for all eligible residents. Leveraging the trusted relationship between our family doctors and patients."
That's what I'm talking about, Singapore!
And I like your updated vaccine bracket with FLiRT for the win, too!
I think the uptake of additional doses is a global in nature.
https://www.nature.com/articles/s41591-024-02939-2
I believe the booster recommendations is in line with WHO advice.
One take from this, for me anyway, is that we are still seeing some durability of the original series.
PS, love your kid's breathtaking talent
Thanks for the update. Tell the artist I admire their work. Marty
Will do! Thanks Marty :)
I'm curious what your take on using metformin during a Covid infection is? There's good data from recent studies about its ability to decrease viral load and reduce the risk of rebound symptoms if given early in an infection. The latest study was published May 1, 2024 in Clinical Infectious Diseases. It is titled, "Favorable Antiviral Effect of Metformin on Severe Acute Respiratory Syndrome Coronavirus 2 Viral Load in Randomized, Placebo Controlled Clinical Trial of Coronavirus Disease 2019."
Hi Tara and thanks for stopping by! This question is great. I plan to try metformin when I get Covid, and if tolerable with GI side effects, finish the course that was used in the study you linked to. I've prescribed it to a few patients with good results, although many more are skeptical and barely agree to take Paxlovid. My "Covidlandia" bit from last month does directly address this, with some links back to previous posts I've done, so please feel free to take a deep dive on the nuances here. I'll post the link, and then cut and paste the relevant text, though you'll have to follow the URL below to be able to click on the relevant hyperlinks:
https://mccormickmd.substack.com/p/april-in-covidlandia
"Another vote of confidence in metformin to prevent long Covid
This is really big news, again.
A 42% reduction in long Covid rates for those average risk patients treated with oral metformin. That’s huge for a disease that is a slowly moving, mass disabling event for millions of people.
Here’s exactly what the study showed in addition to reducing long Covid rates:
In the COVID-OUT randomized trial for outpatient COVID-19, metformin reduced the odds of hospitalizations/death through 28 days by 58%, of emergency department visits/hospitalizations/death through 14 days by 42%, and of long COVID through 10 months by 42%.
Despite headlines this week trumpeting the news, and respected doctors like Paul Sax, MD writing mainstream commentaries, this data is not new. In fact, I’ve been writing about this good quality, randomized, placebo-controlled clinical trial called COVID-OUT for over a year now. For example:
my article entitled “How to prevent long Covid” from March, 2023
my article entitled “My self-treatment plan for Covid” from January, 2024
I shared this stuff on some doctor sites and mostly I got skeptical or even cynical feedback. Doctors (and people in general) can be really resistant to change and new ideas that are not obvious and accepted by the herd. I’ve had very few patients take me up on the offer to try metformin, as many have heard Covid is just a cold now.
It often is not.
So why is metformin finally poised to become a more mainstream treatment for Covid? I suppose it’s because this further data from the COVID-OUT trial published this week in Clinical Infectious Diseases really focused on a mechanism of action. Metformin reduced viral loads in the body by 3.6-fold.
Paxlovid also reduces viral loads by up to 90%, by the way, and I’ve written about how it has been discarded prematurely by many thought leaders as well. But I digress. Back to metformin.
Beyond the viral load reduction as a mechanism, metformin has other effects that were not measured in this trial. I’ll quote my previous article:
Metformin has some plausible mechanisms for why it might help reduce long Covid, including immunomodulatory effects, complement system protective effects, blunting damage of dopaminergic neurons, and mitochondrial protective effects.
So bottom line here is that long Covid is what I fear the most for myself and my patients… not so much hospitalization and death anymore. I also fear cumulative damage that goes undetected and shows up later, unofficially counted by ever-increasing excess mortality in the world; Covid has probably claimed 30 million precious lives. When people ask me for advice I’ll err on the side of aggressive treatment."
Hope this helps and provides some validation for your astute question.
Thanks for your post.All your posts help me stay healthier and communicate with my pcp better.
We just got back from Hawaii (Big Island). I was wondering why I was seeing a higher incidence of masking in grocery stores (below 5%, but noticeable). At least a few "essential workers" were staying on top of things.
We saw zero masks on the flights back to Houston, where we noticed a large collection of unclaimed suitcases roped off in the baggage claim area, likely belonging to still-quarantined passengers who came on a United flight from Vancouver earlier that night. Ironically, I had masks with me, but failed to check local trends and use any. Sigh. Staying aware and proactive takes more work.
Your comments on the benefits of good ventilation are likewise relevant to us residents of over-air-conditioned Houston. Open ventilation practices here increase our AC bill. Masking here is perceived as a political statement. For instance, when I voted in the 2022 primaries, I decided to participate in the Republican polls to support those rare specimens that weren't spouting anti-vax, anti-mask, anti-Fauci tirades on their websites, so that if a Republican wins a specific post, they'd be less likely to be irrational. Standing in line to vote, I was the only masked person in the group. Almost all those waiting in the Democratic line were masked. One well-meaning lady turned to me and told me that the Democrat line was "over there" (pronounced "ova they-ah".) She had trouble processing my response that I was where I meant to be.
Jerry this is so fascinating! I'll keep my fingers crossed that the trip to Hawaii did not bring any unintended souvenirs back home for you. Would absolutely love to visit someday, I've never been. We have a long flight coming up and I plan to wear an N95, which really sucks, but has not failed me yet. People definitely resent you when you intrude upon the group narrative that "it's all good now." But in Philly (80% Democratic) there is a live and let live vibe so although masking rates are really low (and that's OK for people to decide, I'm not commanding anyone!) at least no one has told me at the airport in a Philly accent: "Yo, why are youse guys masking?"
I would happily welcome the kind of Republican you are talking about, we need many more of them to stand up to the shamefulness and reclaim the better parts of their grand old party. Ok sorry for the politics, I'll head over to HCR for that ;)
Some data out claims that getting the Pneumovax immunization can also decrease our chances of contracting Covid. Any thoughts on that? Also, what a beautiful painting, please compliment your artist for me!
Hi Nurjam :) I'm impressed you caught this study, too!
I wrote a little post about this back in March in case you want a deeper dive, here is the link and a quick quotation. And your compliments shared with daughter who is getting an artistic confidence boost from this, so thanks!
https://mccormickmd.substack.com/p/pneumonia-shots-also-help-against
"So here is the bottom line from the systematic review of 16 prior studies, just published last week in the Journal of Infectious Diseases:
In children, data from 4 studies showed that Prevnar cut influenza rates by 41% to 86%. That’s comparable to a flu shot.
In children, infection rates with other viruses, including coronaviruses, parainfluenza, and human metapneumovirus were also significantly lower.
In adults, Prevnar reduced serious lower respiratory infections caused by several common viruses by 4% to 25%.
In adults, Covid outcomes like diagnosis rates, hospitalizations, and deaths in the hospital were all reduced by 33%. These results were before Covid vaccines were available.
In adults, lower respiratory infections like bronchitis and pneumonia caused by influenza A were up to 13% to 36% lower."
Thank you, love it!
Where do KN95s rank among mask protection? How close to N95s and how much do you lose in protection? They are much more comfortable to wear
A recent study found them to not be anywhere near as effective as N95s. I think people do not wear them properly. "Relative efficacy of masks and respirators as source control for viral aerosol shedding from people infected with SARS-CoV-2: a controlled human exhaled breath aerosol experimental study" Lancet May 29, 2024.
That said, I wear them in grocery stores. On an airplane it is an N95 or bust.
Thank you. So you think the study should be discounted because of the improper wearing?
I do not know enough about the study to discount. I have not read the whole study *yet* but other studies have been more positive about the KN95. I would just defer to my N95 when I am any place that is crowded or I am not moving: any theater, airplane, public transport. I personally can't risk another infection.
Well answered by Donna below, I'll thank her for that. Publicly available masks run on a continuum of effectiveness, from crummy gators to great N95s. KN95s are very good, but the seal on the face is the variable. Viral dose matters, so duration and intensity of exposures matter in terms of how well a mask will hold up.
Like Donna said, I too wear an N95 on planes, and have personally checked the CO2 ppm while flying and can confirm the ventilation is not adequate (usually hovering around 1500 ppm on flights I've taken). I like 3M Aura.
I never mask outside anymore, and inside depends on prevalent Covid rates and how tight people are packed in, and how long I'm going to be in there. Once again, to each their own, and a lot depends on how high risk we are, and personal risk tolerance!
I think cases are slowly rising here in the PNW. Good friend of mine got it from her roommate (who would not test until it was too late to effectively isolate). I find the the info about CO2 to be fascinating. Pretty sure I picked up my recent case from a poorly ventilated breakfast room in a hotel. I am still kicking myself over it. I am 4 weeks post-acute Covid and I am only now feeling close to normal. Still coughing and my 67 year old brain may never be the same. I will continue to mask in almost all places I go. Just an FYI: Paxlovid can be hard to get. Pharmacies stock very little. I got the last dose at a local Walgreens and my friend with Covid had to check 6-7 before she found it.
Hi Donna - thanks for you other comments here. Good to know about the decreased availability of Paxlovid in your area. Yikes. I wonder if that is a combination of low stocking and increased demand like you are describing in the PNW? Will keep this in mind and on the radar! And no shame in the most recent Covid case. We have to live and take chances. It is getting harder and harder to maintain relationships while playing the Covid game the way we know works. Nonetheless I appreciate your story here, and sincerely hope for your full recovery. I just learned that a close friend who is 50 has been suffering from pretty severe long Covid for over a year now (chest pain and PEM), despite being up to date on vaccines and otherwise healthy. Has some joint hyper mobility at baseline (a risk factor for LC) and did not take antivirals. Not sure they would have helped her individually, but I know you try to leave it all on the field while battling. Again, wishing you well :)
Thank you! Very happy for vaccines and Paxlovid. Pretty sure I'd be a lot worse off without them!
Paxlovid was a game changer for me.
I’m also 67 & will send you good vibes♥️
I am glad to hear that! I would take again (but hope to never have to).
Another well-written, well researched, and thoughtful report. Thank you for keeping us on our toes and keeping caution in the forefront of our minds. We'll certainly be on the lookout for well-ventilated areas and we'll be outside as much as possible over the summer months. You have a very talented daughter. Maybe think about making some prints of her work and selling them or swapping them for some donations to charitable causes.
Hi Mike! Thank you for reading and for your support! I know the constant drone of caution can be annoying at best and insufferable at worst, but I'll keep preaching as long as Covid is still a thing and hoping not to offend people. I think that's part of my job in primary care... no one really likes to hear me drone on about colonoscopies either!
And I think your idea regarding making prints is a great one, we would like to instill a little hustle, entrepreneurism, and charity... many thanks and will extend your compliments to her asap ;)
Personally your monthly COVID updates don’t offend— it’s the polar opposite. As the powerful need to deny COVID is so pervasive, I find Covidlandia a wonderful reality check. Yes, thankfully we can move on a bit, but it’s endemic and as Singapore said— don’t let down your guard. Navigating endemic requires nuance and willingness to be an outlier and your kind, thoughtful, calm updates are incredibly helpful. Please don’t stop.
Just read a great article from STAT on the CO2=less acidic=much longer time to degrade active virus--you'd covered this but it's just so important. I use a CO2 meter but just thought it showed good ventilation. Now I understand that poor ventilation is a petrie dish
https://www.statnews.com/2024/06/04/co2-ventilation-research-virus-airborne-life-haddrell-celebs/
Awesome - will read this later tonight thank you!
And here is a claude.ai digestion of that really technical article I referenced above. The chemistry is tricky but the end result easy to understand (poor ventilation favors viruses in multiple ways):
This article investigates how the pH, alkalinity, and acidity of respiratory aerosols affect the stability and transmission of SARS-CoV-2, the virus that causes COVID-19. The key findings are:
Respiratory aerosols become highly alkaline (pH > 10) after generation due to the evaporation of bicarbonate ions, which increases the pH.
The high alkalinity of respiratory aerosols is a significant factor in reducing the infectivity of SARS-CoV-2 over time.
Increasing the concentration of carbon dioxide (CO2) in the air limits the increase in pH of respiratory aerosols, thereby improving the aerostability (ability to remain infectious in aerosol form) of SARS-CoV-2.
Even moderate increases in CO2 concentration (e.g., from 500 ppm to 800 ppm) significantly improve the aerostability of SARS-CoV-2 variants, including the Delta and Omicron variants.
The improved aerostability of SARS-CoV-2 at higher CO2 concentrations is predicted to increase the overall risk of COVID-19 transmission, especially in poorly ventilated indoor environments.
The authors propose that the seasonal variation in indoor CO2 levels may contribute to the seasonality of respiratory viral infections, in addition to the effects of relative humidity.
In summary, the study highlights the critical importance of ventilation and maintaining low CO2 concentrations in indoor environments to mitigate COVID-19 transmission by limiting the aerostability of SARS-CoV-2, which is affected by the pH and alkalinity of respiratory aerosols.
Thanks for a good update . Many of my patients roll their eyes as I explain about some detail about Covid I heard on TWIV podcasts. They are like most of the country in wanting to be done with Covid. Fun to see someone else who nerds out on Covid , chemistry and study analysis. And I cannot help but think that the primary care perspective is so unique - we see the range from “ it’s a cold “ to Looooonnnnnnggggg Covid . Not to mention post Covid vascular / pulmonary /whatever damage. I get why many of my patients are a bit mystified - after all no one they know has any real trouble from Covid ( except the damn government rules that were imposed of course) . Stay well .
Such good commentary and I live this every day with you! I think Vincent on TWiV, though he does a great job overall, is a bit of a minimizer at the same time actually. if I were Daniel Griffin, I would be constantly redirecting him away from some pretty wrong commentary. For example, on the June 1 episode I just listened to, he is only just now realizing that ventilation on planes is not what they say it is, and questioning whether kids with brain fog are making it up. In this episode of Covidlandia, for example kids who are complaining of fatigue and cardiovascular symptoms, 90% have objective evidence of that, why wouldn’t it be the same with cognitive. Let’s just keep gaslighting kids and women? Anyway, hang in there I’ll keep the nerdy updates coming!
Yes Vincent can be like that . It was a bit ironic when he declared he was done with the Covid vax after 3 . I think he might have later changed his mind and done a 4th . I do want to see Daniel push Vincent a little bit more at times. Daniel is so very gracious and appreciates the spot V gives him. I do note how Daniel brings up Michael Osterholm and CIDRAP from time to time . CIDRAP seems to hold a broader view than Vincent vis a vis Covid . And I wonder - will Lex Fridman have Vincent back for a Covid “review “ ?
Hi Ryan, and thanks again for a wonderful update, and the shoutout! Can confirm that it's a s#!+show here in Australia, to the extent that they cancelled all except urgent elective surgery in the public system in the state I'm in. There were 240 clinical staff off sick the public system statewide the previous week, and they finally "recommended" masks for staff but still didn't mandate it! Still, masking rates went from perhaps 2% to maybe 40%, but that was before I tested positive so don't know what's happening now! I've been consistently wearing N95 at work but had been a bit slack at supermarkets/tram/train if not too crowded, and had a mild but prolonged non-Covid cold a few weeks ago. Spouse who is a GP says this is the worse winter for respiratory infections she's ever seen in all her years of primary care (since 2016). Lots of flu, RSV, mycoplasma, Covid, sometimes in combination! And the kids she's seeing are really sick and there is apparently a shortage of azithromycin. Raises interesting points about vaccination for one respiratory ailment being protective against others. Sadly my family in Singapore don't seem to have very proactive primary care and are waiting for their primary care to ask them to get vaccinated before going despite me nagging them to get vaccinated!
I got tested the evening after I got symptoms, probably due to complacency, and literally exclaimed "oh shit" and ran into the spare bedroom and put a mask on. Kids got vaccinated in February (not recommended in Australia but happily we insisted and the primary care doctor at saw acquiesced. Spouse caught it January so hopefully still immune. Anyway, day 5 for me now and family still not symptomatic. I started Paxlovid and Metformin that evening and could almost feel the Paxlovid kick in (wasn't terrible to start with, but felt basically normal after the 3rd dose) but still tire easily. Also yucky Paxlovid mouth but I'll cope with that! Thanks for the reminder about adequate ventilation, but it feels like banging head against the wall trying to get traction with schools etc. Kids' (public) school just spent $3 million for a "kiss and drop" built within 3 months, but not a cent allocated to air filters despite over a year of us asking for it.
Anyway, sorry for the long post, but thanks again for the update! Hope you and your readers keep well!
Zhong, thank you for the generosity of your time posting this comment and status report! Here’s to your speedy and complete recovery. I know the Paxlovid taste, metallic and bitter to me. Please let me know if you stomach the entire metformin titration upwards (I think week 2 is 500mg qam, 1,000 qpm). Most folks don’t bother trying it here, but among the few for whom I have prescribed this for, I would say about 50% stick with it, the rest feel too crummy with GI stuff like nausea.
The cancellations of non urgent surgeries, and the implicit staffing shortages Australians must be dealing with make me shudder… those kinds of meltdowns affect everything from surgery to ER to primary care and have collateral detrimental effects on health outcomes overall. Not your fault at all!
We are traveling this week and doing a lot of museums (masked but Enro quality) and even some indoor restaurants unmasked when the weather cool and rainy like today, so I may be joining you soon 😔
N95 on plane and thinking I’ll try switch back over to that tomorrow as the last museum was horribly packed and ventilated.
Just can’t play this thing perfectly and still have a family and friends.
Once again wishing you well, and I won’t comment on everything you’ve stated here except that it’s been bet enlightening. Take care!