Covid. It’s On. Again.


Perhaps you want to be less of a sitting duck for the holidays with Covid, flu, and RSV on the prowl.

I’m broadcasting a quick heads up from my small examining room in the real world of primary care. I live here. The media and news sources are right – Covid, RSV, and influenza are surging right now. This was predicted. It’s the right time of the year. Vaccine and booster uptake has been abysmal. And some scientists believe Covid may be damaging our collective immune systems to varying degrees, kids included. No one wants to hear that. But if you want a very credible deep dive into the theory that immune system dysregulation is potentially occurring with each Covid infection, please review this resource from Memorial Sloan Kettering, or this less alarming review by Your Local Epidemiologist, or the worst case scenario in this cherry-picking of the most concerning studies.

Suffice it to say that we’re all going to get Covid, it’s not great to keep getting it, and most of us have already had it at least once. Hospitalization and death rates are not confirming any levels of widespread immune system problems to panic about… but trends are worth watching, and erring on the side of precaution.

I’m going to present a quick local update. I’ll review the bigger RSV, Covid, and influenza picture. JN.1 is the variant of greatest concern. We will touch base on ways to reduce risk during family gatherings over the holidays. We can commiserate about how depressing this pattern of diseases surging around the holidays has become each year. And finally I’ll reveal how I truly feel about vaccination and antiviral treatment, for any of you who are still in doubt!

Local conditions

Here in Jersey I can report that the hospitals in my health system are all reporting being at or near capacity in terms of inpatient beds available. I sent a person to the ER from my office this morning, and called triage as I normally do. The ER triage nurse told me the hospital has no available beds. She cited Covid, influenza, and RSV as driving much of the crunch, in addition to cardiovascular events. Patients were not necessarily old, and many in the ER this morning were reportedly in their 40’s-50’s. I can’t confirm that, but my health system sent out an urgent message reinstating masks for staff, as many of us are going out with illness. Staffing becomes a predictable problem again. Patients were strongly encouraged to wear a mask, though few did today even when prompted. I have not taken my mask off in the actual examining rooms since March, 2020 by the way, so no big deal for me to comply.

Bigger picture

RSV, influenza A, and Covid are increasing rapidly. In some areas exponentially. The JN.1 variant is very contagious. The World Health Organization named it a variant of interest.  Furthermore:

The WHO said JN.1 doesn’t appear to cause a higher public health risk than other SARS-CoV-2 variants, but it warned that it could trigger a surge in COVID-19 alongside rises in other viral and bacterial infections, especially in countries entering their winter seasons—a combination of factors that would worsen the respiratory disease burden.

The WHO said JN.1 appears to have higher immune-evasion properties than the BA.2.86 parent virus. The agency added that, despite some reduction in JN.1 neutralization, evidence so far suggests that the monovalent XBB.1.5 vaccines are likely effective, and scientists around the world are actively monitoring the impact of the vaccine.

RSV seems to be peaking, which means there is a lot of it.  CDC influenza maps are getting uglier. I am also seeing people with back to back infections involving some mix of these three or another virus.

Ways to reduce risk over the holidays

Some ideas, updates, and reminders:

  • If you are sick, stay home. Covid is not always showing up reliably on home tests early in the disease anymore. It could also be influenza, RSV, or whatever else out there. A study just published in Clinical Infectious Diseases found :

    • Peak viral load seems to be on the fourth day of symptoms.

    • Using Ct values to predict rapid antigen results, the researchers estimated a sensitivity of 30% to 60% on the first day of symptoms, rising to 80% to 93% on the fourth day of symptoms.

    • Early in the pandemic, they wrote, a single negative antigen test had “reasonable negative predictive value,” with studies reporting 90% to 95% sensitivity in the first week of symptoms. Now, overall predicted sensitivity in the first week is about 60% to 80%.

  • Consider rapid antigen home testing before getting together with higher risk family members anyway. 30% sensitivity early in the course of infection before symptoms really start up can still be better than nothing. A subscriber to my Substack recently shared her experience:

    • “A friend wrote me before attending a holiday sing-a-long party to ask whether I thought she should ask the host to have everyone test. I wrote back absolutely yes, cited Dr. Jetelina’s last update post, and Lo, everyone tested, and Lo again, two people tested positive who hadn’t recognized their symptoms for what they were, and stayed home! Little victories, eh?”

  • Crack some windows for better ventilation.  I’ve written about this before, citing good evidence that ventilation really matters. Viruses like SARS CoV-2 hang in the air for hours. And the amount of viruses we breathe in makes a difference in terms of whether we get sick, and how sick we get. A big dose of viruses up front puts our immune systems behind a big viral head start. Sure, heating bills might go up $25 at worst with some cracked windows for a night. But feeling a cold draft can be part of the special ambience of Christmas Eve. Of this it will be difficult to convince skeptical guests.

  • Run some air filters if you have them, and the house fan if you have one equipped with decent filters.

  • Consider spraying some stuff up your nose. High quality evidence does not exist to support this practice, but I’ve previously written about the plausibility of creating a physical barrier against viruses attaching to our respiratory mucosal cells, and disrupting local spread in the major factories of viral replication in the nose. I don’t think it would hurt, and it might reduce transmission chances a little. Options include stuff like Enovid, Betadine Cold Defense, and good old fashioned nasal saline sprays and rinses. After an awesome commenter shared a source for Betadine Cold Defense, I admit I’m giving it a half-hearted try along with other strategies in high density situations.

  • Old fashioned masking helps. Very few people are going to be doing this with friends and family unless they have some serious high risk condition, or are very hardcore. I’m not. Nonetheless, masking up in doctors’ offices, on planes, and in crowded indoor situations absolutely helps reduce your risk. The haters are simply wrong. And the better the respirator the lower the risk.

  • God bless the children. And realize that they have been implicated in starting more than 70% of household Covid cases. And 40% of them are still contagious after symptom resolution. Up to 25% are still potentially infectious on day 7. I can’t tell you how many of my otherwise cautious patients get sick from their kids picking stuff up at school. It’s such an impossible game, and wearing a mask at school (even during surges like we are experiencing now) has been so thoroughly trashed by people with hostile agendas that it’s even difficult to type the words.

  • Get vaccinated/boosted. It’s too late to count on much benefit by Christmas Eve from getting a jab 3 days beforehand, but it’s a long winter and the ripple effects from the next two weeks will keep spreading outwards for weeks, if not months to come.  The CDC sent this alert to healthcare professionals last week, and so I’ll share it with you:

    • The Centers for Disease Control and Prevention (CDC) is issuing this Health Alert Network (HAN) Health Advisory to alert healthcare providers to low vaccination rates against influenza, COVID-19, and RSV (respiratory syncytial virus). Low vaccination rates, coupled with ongoing increases in national and international respiratory disease activity caused by multiple pathogens, including influenza viruses, SARS-CoV-2 (the virus that causes COVID-19), and RSV, could lead to more severe disease and increased healthcare capacity strain in the coming weeks. In addition, a recent increase in cases of multisystem inflammatory syndrome in children (MIS-C) following SARS-CoV-2 infection in the United States has been reported.

    •  Healthcare providers should administer influenza, COVID-19, and RSV immunizations now to patients, if recommended. Healthcare providers should recommend antiviral medications for influenza and COVID-19 for all eligible patients, especially patients at high-risk of progression to severe disease such as older adults and people with certain underlying medical conditions. Healthcare providers should also counsel patients about testing and other preventive measures, including covering coughs/sneezes, staying at home when sick, improving ventilation at home or work, and washing hands to protect themselves and others against respiratory diseases.

  • The current XBB Covid vaccine seems to be working well in the real world.  A pre-print study out of The Netherlands was posted last week. Although this was an observational comparison type study, between October and early December 2023 (now!) researchers found a 70% lower risk of hospitalization and a 73% lower risk of ICU admission among the Dutch who received the Pfizer XBB vaccine. That’s awesome.

    And even if the risk of contracting Covid is only reduced by 50% for a month, then 40% the next month, then 30% and so on, I’ll still take that (kind of temporary) lesser opportunity for long Covid and further unknown dangers of repeat infections with new variants. Every case prevented is another break in the long chain of transmission, too.

  • Antivirals help. I’m long on Paxlovid. Up to 90% less viruses creating havoc in our bodies has to be a good thing. It has been shown to reduce hospitalization, death, and long Covid rates. And measuring the true value in preventing long Covid is really difficult, as most patients suffering from this condition are either gaslighted by professionals, or remain unlabeled and missed by researchers cramming data. It can take a long, long time to rule everything else out that could be causing fatigue, shortness of breath, chronic headaches, and many other problems.

    Molnupiravir is another decent option. Remdesivir works if you can find a rare health system still offering infusions outpatient.

~

Ok, it’s time to go shopping now. I thought it was important to get this out with the general sense of alarm in my health system today in particular. Full hospitals before Christmas is not good. 

We should find comfort that most people are doing fine with their Covid infections. I see and treat these on a daily basis. But some don’t do well, hundreds of Americans are still dying each day, thousands are picking up long haul syndromes, and we don’t know what Covid’s long, long game has in store for us. So at this time I prefer to reduce my risk when I can, while still being a social human being who needs a hug, and tall, stiff glasses of eggnog like everyone else.

Take good care.  Join me on Substack as a New Year’s resolution to miss fewer vital and overlooked ideas in primary care. Article first published here.



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