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COVID-19 comeback calls for patience

The U.S. just passed a heart-breaking milestone, with more than 1 million deaths reported from COVID-19. With a resurging virus, things continue to change for the Charlottesville area – and the rest of the country. Our local expert and UVa immunologist, Dr. William A. Petri, answers your questions in this confusing time.

Parents of children younger than five have been waiting for word on vaccination for them. Pfizer just announced Monday that its studies show that three doses of its vaccine offer strong protection for these youngsters. What would you advise parents of this group?

Vaccines for the six-month-old to five-year-old age group of children will likely be approved sometime in June. These vaccines are somewhere between 35 to 50% effective at preventing mild COVID-19, and more effective for prevention of the severe forms of COVID-19. What we have to remember is that these vaccines were designed against the original COVID-19 virus that started the pandemic. And as I was discussing earlier, the new subvariants of omicron are relatively resistant to these new vaccines.

So, I would recommend having your child six months of age to five years of age vaccinated when these vaccines become available, because they’re safe and effective at preventing the most severe forms of COVID-19. What we will see in the future is boosters for these vaccines that will be more specific for the circulating variance of COVID-19.

Dr. Petri, I have just heard on the news that some people have had rebound symptoms of COVID-19 after taking Paxlovid. I have chronic lymphocytic leukemia. None of my four coronavirus vaccinations produced any antibodies, although recent injections of Evusheld did produce antibodies. Given my immunocompromised status, I am wondering if I get COVID-19, if it would be better for me to have injections of Remdesivir, rather than to take Paxlovid.

You are better off getting Paxlovid to treat COVID-19 if you unfortunately get infected. It is evident the about 2% of people taking Paxlovid for COVID-19 have a rebound – that is, a return in symptoms after completing the treatment. And it’s not clear whether that rebound is due to the infection still being present or for other unclear reasons. Since it is, however, only 2%, it really makes good sense to continue using Paxlovid as our number one “go-to” antiviral for COVID-19. Paxlovid is 90% effective at preventing COVID-19 from getting so severe as to require hospitalization. It is widely available with a prescription from your health care provider and is effective during the first five days of the illness.

The biggest issue with using Paxlovid is actually not these rare rebounds but instead very common interactions of Paxlovid with other medications. So, it’s important for your health care provider to review your current medications for drug-drug interactions. If you’re unable to take Paxlovid because it interacts with another medicine you are taking, then the other pill that we have to treat COVID-19 is called molnupiravir, trade name Lagevrio. It is less effective but does not interact with other medications, with the main contraindication to its use being in pregnancy. Remdesivir, as you know, would need to be given intravenously and therefore would be an impractical choice for outpatient treatment of COVID-19, although it is the work-horse antiviral for patients who are hospitalized.

It is great that you and your health care provider knew to test your antibody levels after vaccination, because there are several immunocompromising conditions which result in the COVID-19 vaccine not working, of which leukemia is one.

For those who are unfamiliar with it, Evusheld is used to prevent COVID-19 in those for whom the vaccine does not work. It is a combination of two long-acting monoclonal antibodies that neutralize the spike glycoprotein of the original omicron variant of the coronavirus. One injection of Evusheld did provide at least six months of protection against infection with omicron and the dose was doubled in the early spring to provide added protection against the first subvariant. Unfortunately, we are now up to our 4th subvariant of omicron BA.2.12.1 in Central Virginia and it is not yet known the extent to which Evusheld will protect. So, thank goodness we also have antiviral pills such as Paxlovid to treat COVID-19.

By the way, we have a local connection to Paxlovid. The vice president at Pfizer that directed the development of Paxlovid is Jay Purdy, who received both his MD and his PhD in my lab from the University of Virginia!

I recently read that older people, even when vaccinated and boosted, made up a sizable component of those hospitalized in recent COVID-19 outbreaks. Can you explain what is going on here? I know older people are at much higher risk of COVID-19 than younger people, but I am concerned this means the vaccine is not as effective as we thought it was. Do we know whether these people had other underlying conditions, in addition to their older age, that put them at risk? Thank you!

You are correct their age is the number one risk factor for severe COVID-19. Someone who is 85 years old is almost 100 times more likely to have severe COVID-19 then someone in their 40s. Another way of looking at it is that 90% of deaths have been in those 55 and older. And almost all the patients currently hospitalized at UVa with COVID-19 pneumonia are middle aged to elderly. That being said, the biggest impact of the vaccines has been in preventing hospitalizations and death, especially in the elderly.

Of course, we all need to have our COVID-19 vaccines boosted, including as announced this last week children ages 5 and up who’ve received the primary two-shot vaccination. We know that boosting provides months of added protection against hospitalization and severe disease. Omicron and its subvariants have evolved to evade and antibodies against the viral spike protein. So, it’s clear that a new generation of vaccines will be needed to provide the best protection against these new variants and sub-variants.

Mask requirements for flying have been lifted. Do you think it’s safe to fly now? What about wearing a mask in other public settings, such as a grocery store or doctor’s office?

Air travel is no more no less safe than any other activity where you are with the public in an indoor setting. In Charlottesville and Albemarle County, we are currently at a medium level of transmission based on data from the CDC. At a medium level transmission, if you are at high risk for severe illness, for example if you are 55 years of age or older or have pre-existing heart lung liver or kidney disease, then the recommendation is to wear masks and take other precautions.

I personally have gone back to wearing masks in indoor public spaces ever since the transmission level went from low to medium. Part of the reason that I do so is not just the medium levels of transmission, but that the subvariant of omicron that is being transmitted is more resistant to the immunity conferred by the vaccine or prior infection. So, we’re in a situation where we’re seeing higher levels of transmission of a virus that is more apt to evade the vaccine or even a prior omicron infection.

The other recommendation right now is that if you have cold or flu or hay fever symptoms is to get tested for COVID-19 and not to participate in public events where you could expose other people until you know that you do not have COVID-19.

Do different strains of COVID-19 cause different symptoms?

Omicron and its variants are less likely to cause the severe pneumonia that primarily brings people into the hospital with severe COVID-19. That being said, the UVa medical center has gone from no patients with COVID-19 immediately after the omicron wave to 35 patients last week due to the new wave of omicron variants. So even though the infection in general may be less severe, with lots of people being infected, unfortunately some are going to develop pneumonia that requires hospitalization.

With another wave apparently coming our way, I just wonder: how long is this going to last? Is there any way to stop this virus from mutating?

It seems a long road to reach the so-called herd immunity where enough people are immune to COVID-19 to prevent its future transmission or prevent virus mutation to new variants. I anticipate that every year we will have a booster for COVID-19 to give added immunity against the new variants, in a similar manner to how we get an influenza booster every year to protect us against the new mutants of influenza.

I have not given up hope that the world can intervene in a way to prevent new variants from arising. This will require a huge international effort, similar to what I’m involved with at the WHO with poliovirus eradication. For polio this has been a 30-year campaign of vaccinating children around the world, and due to tremendous international cooperation, we are now very close to the goal of eradicating polio.

A recent story in the New York Times looked at efforts in the U.S. to stop COVID-19 compared to efforts in Australia. The comparison didn’t make the U.S. look so good. Are there lessons that we can learn from?

I also read that article also found it provocative. I believe the major thesis of the writer was that in Australia there’s greater trust of institutions and health care then in the U.S.

Comparisons such as that are useful to the extent that they point out to us areas where we need to improve here in America. I think all of us would agree that we have a problem with access to medical care in the U.S. especially, for some segments of the community. One very good thing here in Charlottesville in response has been the outreach from UVa to the community to provide COVID-19 vaccine and diagnostic testing.

I hope an outcome of the pandemic will be added trust in medicine and science, as science is saving lives through vaccinations and treatments, and medicine through the care that nurses, respiratory therapists, physicians and so many others have provided and continue to provide.


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