To Vaccinate or Not---The Rat Flu Odyssey Continues

[PB]

It seems that, just as the covid symptoms vary widely, Paxlovid's effect does as well, but it does significantly reduce symptoms on average, and penny mouth is pretty tame for a side effect.

Shaping up to be a big shot season: Covid, RSV, Flu .......

[old goat]

I got covid from my wife. She had a "cold" but didn't test herself until after which time it was too late for Paxlovid. My symptoms were greatly improved within hours of taking the first pill and gone by the next morning and went out to shovel a few feet of snow off my deck. She stayed sick for 2 more weeks. My taste was not affected. (Unlike when I take diamox for altitude and can't drink carbonated drinks.)
Pro tip--it's a lot easier to get Paxlovid when you have a medical license and can write Rx for yourself.

One important caveat on test to treat--for pharmacists to prescribe they have to have persons medical records and lab work within 12 months, which seems to limit availability considerably.

[riser4]

have a medical license and can write Rx for yourself.

Duuuude.

[bodywhomper]

Lost an ex-aunt that way.

[Trackhead]

Pro tip--it's a lot easier to get Paxlovid when you have a medical license and can write Rx for yourself.

One important caveat on test to treat--for pharmacists to prescribe they have to have persons medical records and lab work within 12 months, which seems to limit availability considerably.

I prescribe based on patients report of positive home test, no need to test to treat in my setting (Urgent care, ER, clinic).

[highangle]

[old goat]

That 43% figure is misleading. Looking at the JAMA article the absolute difference in excess deaths was 7%--the relative difference was 43%. The difference between absolute risk and relative risk is this--if, as an example something increases your risk of dying from 1% to 2% that's a 1% absolute risk increase but a 100% relative risk increase, which greatly exaggerates the risk. This is a favorite statistical manipulation medical researchers like to use to make something seem more significant than it is. 7% increased risk in excess deaths is still significant of course, although if you look at the overall risk of death between the two groups the absolute risk would be even smaller.

[old goat]

I prescribe based on patients report of positive home test, no need to test to treat in my setting (Urgent care, ER, clinic).

Kaiser does the same--self reported home test is good enough. Not a lot of PCR's being done, not even on staff that gets sick.

[bodywhomper]

PCR testing seems not too effective at diagnosing current infection for paxlovid rx because they can pick up previous infections many days (weeks?) after one is not infectious. Right?

[Mofro261]

PCR testing seems not too effective at diagnosing current infection for paxlovid rx because they can pick up previous infections many days (weeks?) after one is not infectious. Right?

Incorrect.

If you are getting Pax it better be within 1-3 days of symptom onset, not 2 weeks after your last round of infection.

If you had a round of COVID previously you may test positive as much as 21-28 days post symptom onset, but rtPCR is not routinely positive past 3 weeks post infection.

[bodywhomper]

We’re saying the same thing.

Supposed you went to dead and company shoe in OR, caught covid but was asymptomatic, then you went to dead and co in SF, and then you had the sniffles several days after that series of SF show (from a different virus or allergies). Because of the news that many attendees at the SF shows came down with covid, you go get a pcr test to confirm if your infected and get pax rx if your infected. You test + on the pcr because of your asymptomatic infection from 2 weeks prior. You shouldn’t be rx for pax, right? In other words administering a pcr test would provide poor information for a pax rx. Correct?

[Mofro261]

We’re saying the same thing.

Supposed you went to dead and company shoe in OR, caught covid but was asymptomatic, then you went to dead and co in SF, and then you had the sniffles several days after that series of SF show (from a different virus or allergies). Because of the news that many attendees at the SF shows came down with covid, you go get a pcr test to confirm if your infected and get pax rx if your infected. You test + on the pcr because of your asymptomatic infection from 2 weeks prior. You shouldn’t be rx for pax, right? In other words administering a pcr test would provide poor information for a pax rx. Correct?

NO ONE gets PAX for being asymptomatic, full stop*. If you are have symptoms, take a test and if pos, get on the pax if possible. Are you testing for anything but covid, and if concerned why didn't you test before heading off to another show?

Maybe wear a mask if you are that prone to picking up multiple different infections within a short period on time- there may be an underlying issue with your health.

But really BW, that's quite a hypothetical stretch you are arriving at.


* per Mount Sinai Health System Treatment Guidance for SARS-CoV-2 Infection (COVID-19)and CDC- July 2023

Paxlovid™ should be considered as first line for the treatment of symptomatic patients (≥ 12 years of age weighing at least 40 kg or 88 pounds) who have ≤ 5 days of symptoms, have confirmed or high suspicion for COVID-19.

Paxlovid™ is not authorized for pre- or post-exposure prophylaxis or asymptomatic COVID-19.

[SumJongGuy]

Pax has hoops to jump through because there probably isn't enough to give it to everyone who thinks they might need it someday.. Remember during the Anthrax scares what happened with Tamiflu supplies???

[bodywhomper]

But really BW, that's quite a hypothetical stretch you are arriving at.

That hypothetical is describing scenarios that I’m actually observing in my area, through private parenting FB groups, conversations with friends, or small biz owner closing shop while they recover. People traveling together for concerts, festivals, etc. where some of the group develop mild symptoms but some do not, and some test positive with RAT but some do not and lots of questions are raised. Plus several continue to go about their regular lives w/o changing anything (or testing) because it feels like a mild cold (or allergies). Watching this play out over the past 4 weeks. It’s out in the community. Many are not testing. My area does not have wastewater surveillance. There appears to be other viruses in circulation (and allergens) that mimic mild symptoms.

My point was that my understanding is that using rtPCR tests can further confuse the issue - are the new mild symptoms due to covid or something else(?) (which was in response to old goats comment).

[old goat]

Maybe wear a condom if you are that prone to picking up multiple different infections within a short period on time- there may be an underlying issue with your health.

FIFY

[bodywhomper]

Weren’t peeps having Covid and another virus at the same time or immediately after having covid a thing being documented last fall? Theorized to be related to temporary dysfunction (or dysregulation) of some sort of T cell as a result of covid? And less temporary for some of those with long covid?

[bodywhomper]

Apparently, infections are on the rise, a lot. Dr JP Weiland, a disease modeler, is stating that the US nationwide wastewater surveillance data posted end of last week indicates that 1 in every 55 Americans is currently infected with covid.

A new long covid piece came out from that large VA cohort. 2-year study. “Over the span of 2 years of follow-up in the nonhospitalized group, risks declined and became not significant for 69% of the examined sequelae.”

Here’s a WTF statement: “Over the span of 2 years of follow-up, 25.3% (18.9, 31.0) of the DALYs due to PASC were contributed from the second year ….” Meaning that those 25%-Wes came down with long covid at least one year after infection.

https://www.nature.com/articles/s415...02521-2#MOESM2

[Toadman]

Aunt and Uncle were on vacation in Scottland, and both got COVID. Both are vaxed and boosted. Somewhere between mild and moderate symptoms. Cousin and his wife also tested positive after their daughter's wedding in Minneapolis. We were with them two days before they tested positive. We somehow have avoided the COVID despite having been on a few trips and family gatherings. Probably only a matter of time before it gets us.

[LongShortLong]

To bodywhompers Q about back to back infections. And to say what Mofro said in different words.
My understanding of virology works like this. The immune system upon sees a threatening virus and goes ham on it. The various phases of the immune response are strong enough and long acting enough, that the same virus will not provoke a noticeable response for several months following initial clearance. Basically after infection, the immune system has a BOLO for that virus - if it shows again, it'll be arrested before it can cause trouble. AFAIK specifically for covid, a different strain* is the same virus.

This means that if you have back to back infections, they are almost certainly different viruses (or bacterias, mad cow prions, etc). So, if you had covid 6 weeks ago, and test positive today, you don't have covid again. If you didn't test 6 weeks ago and are positive now, you probably have covid. If you catch covid, early treatment with paxlovid, remdesivir, or molnupiravir is CDC recommended depending which you qualify for (if any). If you qualify and your doctor tells you to wait, your doctor is making a mistake. Age 50+ is one qualifying condition.

Nature can of course do what it wants, and maybe you're special, or covid has become special and no one has noticed yet. But it's very unlikely you had back to back covid infections. 6 weeks - no. 6 months - maybe.

I'm not a virologist, not even a dentist. But I did audit an online virology course, and have read far too much about covid. Consult the CDC - their advice is pretty solid at this point. Also the treatment recommendations do change as CDC reviews more studies. Your doctor may be misinformed. I may be misinformed. CDC.

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* I don't know for sure but maybe you could catch two different flu strains back to back. Exposure to a dengue strain leaves you worse off if the next strain gets to you. Wait, what? Immunity and viruses are complicated like that. I've seen concern that covid exposure may reduce your immune memory for all viruses.

Why are MMR, smallpox and some other vaccines forever/very long lasting and covid or flu vax isn't? The theory I subscribe to is viruses with a long incubation period (week +) are present in the body for long enough that the immune memory response can get ahead of the infection. In contrast, many respiratory viruses begin replicating immediately in your epithelial cells and cause symptoms before most of the immune memory response kicks in. There is some memory immunity in the epithelial cells but it doesn't last as long. I've vastly simplified immune system complexity, similar to "closed for avalanche hazard." You could take a class I watched Vincent Raccianello's

[bodywhomper]

My point was that rt-pcr tests may not be as effective in identifying active and contagious infection because they provide positive results for a long time after infection due to sensitivity, because covid is spreading in the community, and because co-infections were (and have) become more common (cdc released a PSA about co-infections last fall). Plus allergies.

Since 2020, I’ve known a few people that had positive rt-pcr tests during their typical season allergy time and thought they were just experiencing allergies. Each was testing not because of their symptoms but for other reasons, eg surgery. Because it was an rt-pcr test, though, it was never clear if they were infectious at the time or were past that period of infectiousness when they tested.

Btw, CA dept of Public Health just changed their recommendations for following the cdc’s new guidelines for indoor ventilation/filtrations. This should trickle down to schools and other public buildings. Hopefully other states are also doing this. Improved indoor air quality will improve public health.

My kid just started his freshman year at college. One class has been canceled for at least this week because the professor tested positive over the weekend. Wife turned in paperwork for her new job today. The HR person, who was talking to their boss (about 6 feet away) donned a mask as my wife approached their desk and the HR person said, “my husband tested positive for covid over the weekend, but I am testing negative so far.” They removed the mask as my wife walked away from the desk…. At least some people are testing!

[SumJongGuy]

Wastewater testing is showing a surge, as are hospitalizations here. Glad I'm still working from home. Still avoiding crowded elevators.. but walking around in a store or briefly interacting with others still mask free. In person meeting weekly with 3-5 people in a trailer house room is still mask free.. but probably shouldn't be the way things are trending again.

[TNKen]

Resurgence here too. Supposedly a new booster for this variant to be distributed. But of course it will have run its course.

[The AD]

I'm starting to see more and more people wearing masks in public again. I haven't yet, but will be monitoring the situation.

[LongShortLong]

My point was that rt-pcr tests may not be as effective in identifying active and contagious infection because they provide positive results for a long time after infection due to sensitivity, because covid is spreading in the community, and because co-infections were (and have) become more common (cdc released a PSA about co-infections last fall). Plus allergies.

Sounds like a policy question then. Are we protecting the public from pandemics? Protecting the individual from disease? Protecting the insurance company's bottom line?

To what degree do rtpcr's stay positive? I thought that was somewhat rare, like less than 10%, maybe less than 1%. Same for how often does someone have an infection of any type two weeks earlier. Symptoms -> test -> positive seems like a pretty strong covid diagnosis, though I'm not a doctor. As conservative as we are with approving treatments, I lean toward treatment without a strong argument against. OTOH If no symptoms, screening test -> positive may not be as strong, but given the high effectiveness of timely treatment, it should probably still be given unless community prevalence is really really low.

E.g. if prevalence is 0.1% and false positive rate is 1%, then 90% of positives aren't covid, and some percent of the true positives are post-infection when early treatment won't help. So maybe only 1 in 20 positives could be helped. In that case start to consider the patient's risk profile. But you wrote above that current prevalence is close to 2%. So we're going to find 2 true positives for every 1 false positive, and treatment would help 1 in 3 positives.

Paxlovid's effectiveness approaching 90% when given early, makes a strong argument in favor of treatment.

[bodywhomper]

Dr Michael Mina’s simple explanation is that PCR tests will show positive 20+ days after one is infected and long past when they are infectious. There’s other data available from PCR tests that can provide insight about whether one is likely still infectious. Using our free clinic, the reported pcr test results were positive, negative, or testing error, but none of the nuanced details were provided or interpreted.