April 2023 Newsletter

Welcome to the April and a Half 2023 Newsletter for

Santa Monica Primary Care.

While published later in the month than usual, the information is not any less timely! In this issue we will cover LA County’s COVID-19 Emergency which ended March 31st, 2023. We also cover our clinic’s Spring experience with COVID-19and provide guidance on “new” booster recommendations.

End of LA County’s COVID-19 Emergency

With very little fanfare, Los Angeles County’s COVID-19 Emergency ended on March 31st – withthe major impact being the closure of County-run testing facilities. But beyond that, not muchchanges. An indoor masking mandate was lifted 13 months ago and face coveringrecommendations for the general public ended two months ago. In healthcare settings, maskscontinue to be required for healthcare workers providing direct patient care or working in patientcare cares. This, however, is a Los Angeles County only requirement as at other healthcaresettings in California, no masks are required whatsoever. It was certainly reasonable for the County to close testing sites as weekly testing rates are thelowest they have been (at 148 tests per 100,000 population) since May of 2020 (Figure below).At their maximum, 2745 tests per 100,000 were performed the week ending 1/11/2022.

Smoothed SARS-CoV2 Daily Testing rate (per 100,000 population): Los Angeles Country

Free testing remains available at LA County Public Health clinics.

Current COVID Incidence and Prevalence

The Los Angeles Times offered this outstanding turn of phrase when reflecting on the lifting of the COVID Emergency:

“But just as March 2020 is now indelibly etched in our collective consciousness— a watershed moment when daily life screeched to a — March 2023 may be remembered as when COVID-19 officially went from top of mind to back of mind.”

From my perspective, I was concerned that we would experience another January surge as wehad in 2021 and 2022 but that never materialized (Figure below)

Smoothed Daily Incidence Case Rate (per 100,000 population) of SARS-CoV2: Los Angeles Country, California for 2020 (Blue)

We are now in our current and expected Spring lull in cases, seen in all years of the pandemic -although 2020 should be interpreted cautiously given that we were under shelter-in-place orders.

Current prevalence rates (active cases per 100 population) are the lowest they have been at less than 0.1% – so fewer than 1 case per 1000 individuals – since October of 2022 (Figure below).

Estimated Prevalence Rate (per 100 individuals) of SARS-CoV2: Los Angeles Country, California

Death Rates - At A Historic Low

One common mantra that has been repeated throughout the pandemic is that of “more cases,more hospitalizations, more deaths.” This is a pattern currently holding in the inverse with deathrates also now at historic lows as case rates are at seasonal lows as well. However, in 2023 withearly detection from accurate home testing and widespread availability of Paxlovid, mortalityrates now stand at 0.02 deaths per day per 100,000 population (equivalent to 2 deaths per dayin LA County, with 10 million people). The last time mortality was this low?

The week of March 17th, 2020.

The figure below is a log transformed graph which shows more clearly just how much mortalityrates have dropped/

Smoothed Daily Mortality Rate (per 100,000 population) of SARS-CoV2: Los Angeles Country, California

Santa Monica Primary Care and COVID-19: Paralleling the County’s Experience

Similar to the County’s experience, we too have seen a massive decline in cases sinceNovember 2021 when we had 29 new cases (and 5 repeat infections). Thus far in April we havehad only 3 cases (2 of which were repeat infections)

Total COVID-19 Cases and Repeat Infections by month in 2022/2023: Santa Monica Primary Care

FDA Recommendations for a Repeat (Second) Bivalent Booster

This past week, the FDA amended the terms of its Emergency Use Authorization (EUA) for theModerna and Pfizer bivalent boosters, permitting individuals 65 and older and those withunderlying immunocompromise to have an additional dose (providing that it has been 4 monthsfrom the last).

In conversations with patients about this new recommendation, I’ve found myself clarifying a fewaspects of the FDA’s communication:

  • This is not a “new” booster, it is a new recommendation. The booster is identical to that originally authorized at the end of August of 2022.
  • The Bivalent booster contains mRNA components from the original strain ofSARS-CoV-2 as well as from the BA.4/BA.5 omicron variants. The BA.4 and BA.5variants have not circulated since the Fall of 2022.
  • This recommendation brings the US more in line with the UK and Canada. In the UK, they have referred to the second bivalent booster as a ‘top off’ for vulnerable populations.
  • Fall 2022 bivalent booster uptake was far higher in the UK than the US. In the UK, 65%of those 50 and over received the bivalent booster, and >80% of those over 70 received the booster. In the US, only 42% of the population over 65 had a booster dose. So some of the rationale for recommending a second bivalent booster may, in fact, be to encourage people simply to get their first.
  • The general expectation is that there will be a new booster available in the Fall of 2023which would be updated for circulating variant(s) at that time and also coincide in timing with an annual flu shot.
  • For now there is little compelling reason if one is young and healthy to have another bivalent booster. Individuals that are older (65 and above) with comorbidities or any immunocom promise could think about one at this point, with the context that cases and deaths are currently at historic lows. 

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March 2023 Newsletter

Welcome to the March 2023 Newsletter for

Santa Monica Primary Care.

In this issue we will break down the anticipated end of LA County’s COVID-19Emergency expected March 31st, 2023.We also cover our clinic’s experience with COVID-19 and how that has paralleled that of the County as a whole.

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End of LA County’s COVID-19 Emergency

On the last day of February, the Los Angeles County Board of Supervisors declared unanimously that the last day of March would mark the end of the COVID-19emergency. It seems emblematic of the County’s pandemic response that a political body of 5 individuals representing 10 million County residents would declare it ‘over.’ To date, the County has recorded 3.5 million cases and 33,859 deaths – both no doubt significant underestimates of the virus’ true impact

But looking at the pandemic as a whole (155 weeks of data), the Supervisors do have a point in declaring the emergency phase over. The presumed January peaking of cases seen starkly in the Figure below that occurred in 2021 and 2022never materialized in 2023.

Smoothed Daily Incident Case Rate(per 100,000 population) of SARS-CoV2: Los Angeles Country, California

Estimated Prevalence Rate (per 100 individuals) of SARS-CoV2: Los Angles Country, California

So when looking at incidence and prevalence rates historically and combining such with a lack of an (expected) January surge, it does appear that we are moving away from an emergency state.

Current COVID “Situation

The Los Angeles Times article highlighting the end of the COVID Emergency (link:https://www.latimes.com/california/story/2023-02-28/la-county-to-end-covid-state-of-emergency-in-march) states the following rationale for moving to a less vigilantposture:

“But given the current situation — with vaccines and therapeutics plentiful and hospitalization and death rates having tumbled without the sort of aggressive interventions seen earlier in the COVID-19 era, such as mask mandates and stay-at-home orders — officials said the emergency declaration was no longer necessary.”

To be sure, there is no lack of vaccine availability, both the primary series and the bivalent booster remain available from a variety of sources. Stocks are available because only 17.5% of eligible County residents have received the bivalent booster, although this is slightly better than 16.1% nationally.

“Plentiful” therapeutics, however, this really isn’t the case. Monoclonal antibodies have had their use authorization revoked as they have not demonstrated efficacy against Omicron and subsequent variants. This includes: Bamlanivimab,Estesevimab, Bebtelovimab, Casirivimab, Imdevimab, and Sotrovimab. Even Evusheld, which is a long acting monoclonal antibody used for COVID-19prevention among those who may not have mounted an adequate immune response, has been removed from the market

What is available is Paxlovid which has its clearest benefit among unvaccinated adults who have risk factors for progression to severe disease. Accumulating observational data suggest that high-risk vaccinated individuals also benefit and alarge VA study has shown a 30% risk reduction in long COVID from Paxlovid. Therehas been no difficulty in prescribing or obtaining Paxlovid through local pharmacies.

However, Paxlovid interacts with a variety of medications, most particularly medications for cholesterol, hypertension and migraines as well as blood thinners. For some patients, these medications can be held during the 5 day treatmentwindow but, for others, Paxlovid cannot be given. The only other recommendedCOVID-19 therapeutic in Remdisivir but this is administered intravenously for three consecutive days which each administration taking up to two hours. So, functionally, only one therapeutic is plentiful.

Death Rates - Have They Tumbled?

Hospitalization data are not published in a raw format by Los Angeles County, so we cannot independently evaluate the Board of Supervisors statement about hospitalizations having tumbled. But mortality rates are trending lower after a small rise in November and December 2022. They currently stand at 0.06 daily deaths per100,000 individuals. They peaked at 2.8 daily deaths per 100,000 in mid-January2021 and rose as high as 0.87 in February 2022. The lowest rates (0.03) have been seen in a couple of instances: June 2021 and May 2022.

A factor of 100 makes the County-wide mathematics easy when considering the totals. Currently, 6 County residents (0.06*100) die from COVID daily. At the peak that number was 280 and at the lowest, that total was 3. Extrapolating this out further, COVID at its lowest observed rate (10.95 deaths annually per 100,000population) would place it as the 11th leading cause of death in the County above motor vehicle accidents (8.6) and below colorectal cancer (14.2). Since we wear seatbelts and have colonoscopies, it would seem prudent from a public health perspective that we do something about COVID moving forward.

Smoothed Daily Incident Case Rate(per 100,000 population) of SARS-CoV2: Los Angeles Country, California

Santa Monica Primary Care and COVID-19: Paralleling the County’sExperience

Similar to the County’s experience, we too have seen a steady decline in casessince November 2021 when we had 29 new cases ( and 5 repeat infections). InFebruary 2023 we had only 9 cases, all of which were first infections. Totals fromJanuary 2022 until the end of February 2023 by month are outlined in the Figurebelow

Total COVID-19 Cases and Repeat Infections by month in 2022/2023: Santa Monica Primary Care

Paxlovid Prescribing Patterns and Rebound

Given the significant benefits of Paxlovid in reducing severe disease and hospitalization as well as in reducing the risk of long COVID, I have been a proponent of early use of this medication. Of the 260 COVID cases we have had in the practice since Paxlovid came on the market, 96 (36.9%) received Paxlovid. This is significantly higher than the national rate where only about 20% of those eligible for Paxlovid have received the treatment.

The biggest downside of Paxlovid continues to be rebound which can occur about10 to 14 days after beginning treatment. It is typically characterized by a day or two of very mild symptoms but a positive rapid antigen test. I have advised patients to assume they are infectious and able to transmit the virus during these rebounds, although I have not seen any instances of such.

While Pfizer (who manufactures Paxlovid) reported a 2.3% rebound rate in their studies, a more recent Oxford study suggested that this rate was significantly higher at 14.2% (link: https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciad102/7049992?login=false)

Our observed rate in clinic is higher still at 24% (23 rebound cases among 96treated).

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February 2023 Newsletter

Welcome to the February 2023 Newsletter for

Santa Monica Primary Care.

COVID At A Crossroads
In this issue we will focus exclusively on COVID-19 as 2023 has seen a fundamental(although not necessarily correct) shift in how we are approaching SARS-CoV-2 andthe clinical consequences of infection.
As always, we will start with fundamentals and along the way answer the commonquestions we are hearing in the clinic.

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Is It Still A Pandemic?

This is an interesting question and critical question – one which was posed to me just last week by a patient. Rephrasing the question in epidemiologic terms gives the following, “is COVID-19 an epidemic still or is it endemic.” So are there new case sex ceeding what we expect (epidemic) or is it now a constant presence (endemic)? Case rates in Los Angeles County have declined substantially since our 2022 mid-summer peak. In fact, even the case surge we experienced in November was only half the magnitude (34.8 new daily cases per 100,000 population) of that seen at the summer maximum (64.7).

Smoothed Daily Incident Case Rate(per 100,000 population) of SARS-CoV2: Los Angeles Country, California

This significant decline is more readily apparent when we look at prevalence(number of active cases per 100 County residents). In mid to late July 9.7% of the population had an active COVID infection, and now it is 0.4%.

Estimated Prevalence Rate (per 100 individuals) of SARS-CoV2: Los Angles Country, California

So to answer the epidemic versus endemic question, it looks like we are approaching endemicity with a base expected incidence rate of 8-10 new daily cases per 100,000 population and a prevalence rate of 0.3-0.4%. For large portions of the year we experience this low, steady rate of community transmission but at other times we are having significant surges in activity. The question being – can we predict when those surges might occur? More below..

Is It Seasonal?

If you had asked me this question the last week of December 2022 I would have said‘ absolutely’ but this past January did not follow the trend we had seen in prior years. The figure below shows weekly incident case rate data for every year of the pandemic (2020 Blue, 2021 Red, 2022 Yellow, and 2023 Green). In both 2021 and2022 we had a distinct (and massive to the point that the axis is changed in the figure to accommodate the Omicron outbreak visually) increase in cases beginning in mid November and extending until mid February. That is, until 2023. We had an increase in cases beginning mid-November (yellow line, far right) but then cases plateaued in December and collapsed in January (green line, far right).

Smoothed Daily Incidence Case Rate (Per 100,000 population) of SARS-CoV2: Los Angeles Country, California 2020 (Blue)

Evusheld - Where Have You Gone?

As of January 26th, 2023 Evusheld is no longer authorized by the FDA and will be unavailable to patients. This is a significant and alarming development for immunocompromised individuals as well as those who did not tolerate vaccinations /boosters and relied on Evusheld’s protection. The FDA estimated that “fever than10% of circulating variants in the US causing infection are susceptible to the product.”

This decision was based not on epidemiologic data but instead on laboratory experiments (nevertheless valid) which showed as early as May of 2022 that theBA.4 and BA.5 Omicron subvariants had “escaped or reduced the activity of monoclonal antibodies developed for clinical use” but that Evusheld and Sotrovimab still showed activity (Tuekprakhon et al. link:https://www.biorxiv.org/content/10.1101/2022.05.21.492554v1.full.pdf). In July, Boschi et al. reported that Evusheld’s neutralization was 233 times less active on Omicron than the Delta variant, suggesting of “limited efficacy” (link:https://academic.oup.com/cid/article/75/1/e534/6529556).

Fortunately, there is accruing evidence that polyclonal antibody preparations – suchas plasma from vaccinated and previously infected individuals (terms: convalescent plasma) – would restore protection amongst immunocompromised patients. For amore detailed discussion, readers can refer to this excellent STAT News article – link:https://www.statnews.com/2023/02/06/covid-convalescent-plasma-antibody-therapy/

Blog This Month

Our blog posts this and previous months can be found archived on our website at www.drbretsky.com/blog. Our blog post this month covered booster vaccinations
https://drbretsky.com/12-january-2023-blog-post-on-covid-boosters/

Variants, Variants and more Variants

Both BA.4 and BA.5 (included in the currently available bivalent booster) have now essentially vanished according to CDC data. For Region 9 (which includes Arizona, California, Hawaii and Pacific Territories), BA.4 and BA.5 make up only 0.2% of the currently circulating variants, as compared to 3.9% in January and 90.1% in early August 2022.

KBB.1.5 which was 7.0% of the total variant population in early January 2022 is now the most common at 45.8% with BQ.1.1 and BQ.1 at 31.0% and 13.6% respectively. Initial concerns for an increased transmissibility of this variant were based on observations in China which, until recently, had held to a zero COVID policy and has a largely immunologically naive population. As noted above, cases in our region have decreased in January 2023 during the time period when KBB.1.5 increased infrequency. The general consensus had been that KBB.1.5 does not cause any more severe disease than Omicron or its subvariants.

Link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions).

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January 2023 Newsletter

January 2023 Newsletter

Welcome to the January 2023 Newsletter for Santa Monica Primary Care – our first newsletter of the New Year!

In this issue, we are going to cover the current state COVID cases and will share our practice experience with COVID plus trends in LA County at large. 

We will also highlight a couple of initiatives that we have planned for 2023.

COVID-19 at Santa Monica Primary Care and in LA County

Readers may find it surprising that we actually saw less COVID in December than we did in November. COVID-19 cases in our practice decreased by more than 50% month over month (Graph below). After managing 27 cases in November (one of which required hospital level care), December brought 13 cases.  Of these 3 (23%) were repeat infections.

As I collated Los Angeles County numbers I noticed that we are on row 1035 of the spreadsheet. Little did I imagine in March of 2020 when I began collating the case counts that we would find ourselves in Year 3 of the pandemic.

Cases in Los Angeles County show essentially the same trend, although press reports relying heavily on guidance from County officials would lead one to believe otherwise (link: https://abc7.com/coronavirus-los-angeles-la-covid-cases-new-years-eve/12629266/).  Cases in the County also dropped nearly 50% from 34.5 to 19.8 new daily cases per 100,000 population between from the start until the end of December. 

What County officials are not talking about, however, are persistently elevated COVID mortality rates, despite a decline in cases (Figure below).

In 2020, the average mortality rate was 0.37 deaths per 100,000 population per day.  In 2021 this rose to 0.41 daily deaths per 100,000 population (largely driven by rates >2 in January and early February before vaccines were widely available).

So where would you expect mortality rates to be in 2022 given widespread vaccination, boosters and effective treatments such as Paxlovid.  Much lower, right?  Would 90% be a reasonable assumption – I would think so given that clinical trials have shown up to a 94% reduction in mortality risk with 3 mRNA vaccine doses during Omicron (link: https://www.cdc.gov/mmwr/volumes/71/wr/mm7112e1.htm?s_cid=mm7112e1_w)

Instead we are really only seeing about a 50% reduction in mortality, as at the end of 2022 the mean number of daily deaths stood at 0.18 daily deaths per 100,000 population. Yet I’ve seen little substantive discussion from the County attempting to understand who is dying of COVID and why that is occuring, but instead a dogged / singular focus on reducing cases (which is sound public health policy as reducing cases reduces mortality but there seems to be some subtlety that they are missing). 

One question which I would like to put to Dr. Ferrar is as follows:  Why in July of 2022 was the mortality rate 0.16 with a case rate of 61.8 but in December there was a mortality rate of 0.12 with a case rate of 19.8?

Paxlovid Prescription Trends and “Rebound”

Given the strong clinical data on the significant reduction in long COVID among those treated with Paxlovid (covered in December’s newsletter), utilization rates of this medication have gone up in our practice . Of the 13 individuals who tested positive for COVID-19 in December, 7 elected to begin Paxlovid (53%). Similarly, in November 17 of 27 (63%) took Paxlovid. In October only 3 of 13 cases (23%) chose to begin the antiviral.

The biggest downside of Paxlovid is the “rebound” phenomenon with a return of symptoms and again testing positive, usually about two weeks after the initial positive test. Overall about 25% of the patients for whom we have prescribed Paxlovid experience clinical and testing rebound of the disease but in December only 1 of 7 treated rebounded.

The biggest upsides of Paxlovid include a rapid clinical response where those treated are feeling better, faster – usually in 1-2 days after starting the medication. There is also strong clinical evidence of an up to 30% reduction in the risk of long COVID symptoms as well.

Two New Initiatives in 2023

Each year I try to do “one new thing” in the practice, although it always seems to be more than one. So in the spirit of realism, I will highlight the two new things we will introduce in 2023.

Get DNAbled Program

In 2022 we took our first foray into formal genetic risk analysis with the Galleri cancer screen, based on DNA methylation patterns. While this remains a viable next step (but not a replacement for) routine cancer screening (e.g. mammography, prostate examinations / PSA, and colonoscopy) this year we will also offer a comprehensive pathway for full genome scanning via a partnership with DNAbled – https://getdnabled.com/our-program.html .

For additional detail,see also: https://drbretsky.com/genomic-analysis/

Aledade

In 2023 our Medicare Shared Savings Program will begin formally as part of our ongoing collaboration with Aledade to improve both quality of care and value of care. The lynchpin for this effort will be the annual wellness examination – software developed by Aledade integrates to our Electronic Medical Record platform and identifies patients that are due for such as well as any gaps in their care. Specific emphasis will be on hypertension, diabetes and women’s health initially. Further, with their support, we will seek to manage transitions of care – such as from the hospital to skilled nursing facility and back home. Or, even better, find opportunities to keep patients out of the hospital entirely.

 

We have spent much of 2022 in a slow ramp up position for this effort which will be considerable as Medicare-age patients are a much higher proportion of our practice at Santa Monica Primary Care than most general scope practices – reflecting the age structure of the geographic area.  We have a parallel program already with Anthem Blue Cross that has been running in 2022 and will continue into 2023.  For more information on the transformative work that Aledade is doing with practices across the country, check them out at https://www.aledade.com/our-solutions

Blogs This Month

Our blog posts this and previous months can be found archived on our website at www.drbretsky.com/blog. Our blog post this month covered a couple of COVID topics.

In the first, “Observed Over Expected” we attempted to quantify the true population rates of COVID infection given that the overwhelming majority of cases are now diagnosed by home antigen testing – something that is no longer reportable to the Country Health Department.  The link for this blog is: https://drbretsky.com/13-december-2022-blog-post-observed-over-expected/ 

In our second effort, we covered yet again another Board of Supervisors foray into COVID policy, something I always find interesting because the Health Department falls under the governing scope of the LA Board of Supervisors. Nevertheless, Supervisor Hahn chose to give her thoughts to Fox 11 News.  That link: https://drbretsky.com/15-december-2022-on-protecting-yourself/ 

Variants, Variants and more Variants

Both BA.4 and BA.5 (included in the currently available bivalent booster which has been administered to a whopping 15% of the eligible population over the age of 5) are occupying a smaller and smaller proportion of currently circulating and forecasted variants.  

For Region 9 (which includes Arizona, California, Hawaii and Pacific Territories), BA.5 makes up only 3.9% of currently circulating variants as compared to 90.1% in early August. BQ.1 and BQ.1.1 are estimated to comprise 31.1% (holding steady, was 31.5% in early December) and 40.6 (rising from 31.1% in early December) respectively of the total population of variants (link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions). KBB and KBB.1.5 comprise 7.6% and 7.0% of the total.

A late November CDC study suggests that the bivalent booster provided additional (but not great) protection against symptomatic SARS-CoV2 infection, even in time periods where BA.4/BA.5 sublineages (including BQ1 and BQ1.1) predominated. In this study including over 350,000 (of whom a shocking 25% were unvaccinated) the bivalent vaccine efficacy topped out at 56% (for reference, seasonal influenza vaccine is about 50% effective) amongst those 18-49 who were more than 8 months out from their prior booster. For the highest risk group (those 65+), the bivalent booster was only 43% effective when given 8 months or more after the prior booster. If given within 2-3 months, it was 28% effective. Link: https://www.cdc.gov/mmwr/volumes/71/wr/mm7148e1.htm?s (Note that Table 3 is the most useful representation of their data).

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December 2022 Newsletter

December 2022 Newsletter

Welcome to the December 2022 Newsletter for Santa Monica Primary Care – our final newsletter of the year!

In this issue, we are going to cover the (expected) seasonal rise in COVID cases and will share our current practice experience with COVID plus trends in LA County at large. 

 

We could call this issue the Paxlovid Issue, as there is a lot of detail about its usefulness both in acute illness but also in the prevention of Long COVID.

COVID-19 in the Practice and in LA County 

COVID-19 cases in our practice have increased significantly this month, more than doubling in the past month (Graph below). After the relative lull of September (8 cases), these numbers increased to 13 in October and 27 in November. Repeat cases in September were 18% of the total.  Year-to-date, 25 of our 193 cases (13%) have been repeat infections.

Cases in Los Angeles County show essentially the same trend, although the actual numbers are massive underestimates of the true incidence as positive home tests are not reportable to the County  (Figure below). Cases in the County have more than doubled from 10.5 to 25.9 new daily cases per 100,000 population between October and November. 

Based on these numbers, we would expect 4 cases in our practice at Santa Monica Primary Care when, in reality, we saw 27 suggesting a 6 fold underestimate at the County level.

The current prevalence rate (active cases per 100 individuals) stands at 2.2%, the highest it has been since the end of August.

Paxlovid Prescription Trends and “Rebound”

One of the biggest changes seen in the past month is the greater interest in Paxlovid. Some of this may be due to the large VA study showing a 30% reduction in Long COVID among those treated with Paxlovid (covered in our blog, see #3 below). Of the 27 individuals who tested positive for COVID-19 in November, 17 (63%) elected to begin Paxlovid. In October only 3 of 13 cases (23%) chose to begin the antiviral.

The Atlantic covered the paradoxical prescribing practices surrounding Paxlovid in a piece cleverly entitled “Inside the Mind of an Anti-Paxxer” (link: https://www.theatlantic.com/health/archive/2022/11/paxlovid-covid-drug-hesitancy/672210/).  Nationally, fewer than 1/3rd of Americans over the age of 80 ended up with the medication after a COVID diagnosis, a group who would benefit most from the treatment. The biggest downside to Paxlovid remains rebound, which typically presents about two weeks after the initiation of treatment. While rebound is typically a more mild clinical condition lasting a few days but can still interfere with work and life activities. A positive rapid antigen test coinciding with symptoms will have an individual back in isolation which itself is difficult.

While my experience is that patients feel better faster within 24-48 hours often (this is in contrast to the article which suggests that Paxlovid treated patients are ‘kind of sick’ for two weeks), rebound is a frequently occurring phenomenon. Of the 79 patients for whom we prescribed Paxlovid since the beginning of 2022, 21 of them (26.6%) have experienced a rebound phenomenon (confirmed by positive antigen testing at the time of returning symptoms).

Blogs This Month

Our blog posts this and previous months can be found archived on our website at www.drbretsky.com/blog. Our blog post this month covered in significant detail the compelling VA study showing an overall 26% reduction in Long COVID symptoms among those prescribed Paxlovid.

On Paxlovid and Long COVID:  https://drbretsky.com/21-november-2022-blog-post-paxlovid-and-long-covid/ 

One interesting take away from the article is that the authors go into a bit more detail in an attempt to better describe the utility of Paxlovid by testing its association with Long COVID according to the number of baseline risk factors (‘comorbidities’). Among those with 1-2 risk factors, Paxlovid reduced the risk of long COVID by 33%. The same magnitude of effect was seen among patients with 3-4 risk factors but dropped slightly for those with 5 or more to 30%. 

One downside of the study is that 87% of the study participants were male, something that reflects the VA population as a whole, but making the results less generalizable to women.

The Alphabet Soup of Variants

BA.5 (included in the currently available bivalent booster) is occupying a smaller and smaller proportion of currently circulating and forecasted variants.  BA.5 makes up only 13.3% of the variants seen in the West Coast, Pacific and Hawaii region currently as compared to 90.1% in early August. BQ.1, and BQ.1.1 which were among variants of concern are estimated to comprise 31.5% and 31.1% respectively of the total population of variants (link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions).

However, both of these are offshoots from Omicron (as is BA.5) so we remain hopeful that the bivalent booster will display efficacy against these variants as well, given their genetic relationship.

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November 2022 Newsletter

November 2022 Newsletter

Welcome to the November 2022 Newsletter for Santa Monica Primary Care. 

In this issue, we are going to cover the alphabet soup of COVID variants and try to predict what may happen as we enter the Holiday Season. We will share our current practice experience with COVID cases as well as trends we are seeing in LA County at large. Lastly, we cover this month’s Blog posts, including one on the utility of colonoscopies in reducing colon cancer mortality rates.

COVID-19 in the Practice and in LA County 

COVID-19 cases in our practice have shown a slight rebound as compared to the dramatic slowing of September (Figure below).  The month of October left us with 10 cases, one of which was a repeat infection and the remaining 9 all initial infections. Cases were generally mild (5 of the 10 were characterized as such) but one did lead to hospitalization.  Of the three cases treated with Paxlovid, one led to a rebound phenomenon.

Cases in Los Angeles County, on the other hand, continue to be on the decline, and are now the lowest levels since March of this year (Figure below). The most recent daily incidence rate is 7.4 new daily cases per 100,000 population down from 7.9 the week prior.

This trend runs in direct opposition to comments from the LA County Health Department which notes that ‘coronavirus cases are no longer declining at the rate seen over the summer and appear to have plateaued.’ LA County Health Department Director Dr. Ferrer commented, “We’re no longer seeing a steady decline in cases” as LA County’s case rate began showing week-over-week increases just after mid-October (link: https://www.latimes.com/california/story/2022-11-01/new-coronavirus-omicron-subvariants-bq1-bq11-ba5).   

The prevalence rate is also the lowest it has been in many months at 3 active cases per 1000 residents (Figure below).

Lastly, mortality rates have shown a steady decline since mid-summer and are now as low as they have been since April 2022.

BA.4/BA.5 Bivalent Booster Uptake Remains Slow

In August, the FDA authorized the use of Moderna and Pfizer Bivalent Vaccines for a single additional booster dose to be given at least 2 months after completion of a primary series or the most recent booster dose of a monovalent (original) COVID-19 vaccine. The Pfizer booster is authorized for individuals 12 years of age and older. The Moderna for those 18 years and older.

According to the latest CDC data (link: https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-additional-dose-totalpop), only 22 million – or 7.3% of those eligible – have received a bivalent booster dose.  This has increased from 7.6 million (3.5%) last month at this time.

Blogs This Month

Our blog posts this and previous months can be found archived on our website at www.drbretsky.com/blog. As a bit of a departure, we covered a recent report suggesting that colonoscopies were not as effective in reducing colon cancer mortality. While this generated a fair amount of press coverage, the study itself was actually not all that compelling and certainly was not enough to change clinical recommendations of colonoscopy as a screening tool

On Colonoscopies:  https://drbretsky.com/11-october-2022-blog-post-on-colonoscopies/

We also covered COVID-19 in 2022 as compared to 2020 and 2021 in our second blog:

https://drbretsky.com/13-october-2022-blog-post-a-crazy-covid-year/

The Alphabet Soup of Variants

BA.5, BQ.1, and BQ.1.1 are among the ever growing population of variants of concern. But, in reality, tried and true BA.4.6 and BA.5 make up 84.6% of the variants sequenced across the United States (link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions) and 83.3% of the variants seen in HHS Region 9 which includes California, Arizona, Nevada and Hawaii. While the proportion of BA.4 and BA.5 is decreasing over time (Figure below), they are nevertheless the overwhelming majority of variants seen both regionally and nationally. With booster vaccines that are directly matched to these variants, we should continue to see decreasing case rates and mortality rates.

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October 2022 Newsletter

October 2022 Newsletter

Welcome to the October 2022 Newsletter for Santa Monica Primary Care. 

In this issue, we are going to try to triangulate the state of COVID-19 in Los Angeles County. We will share the current practice experience with COVID and explain how the bivalent boosters might be so exciting. We will also cover the Blogs posted by Dr. Bretsky this month.

1. COVID-19 in the Practice and in LA County

COVID-19 cases in our practice have slowed dramatically (Figure below) with only 5 cases reported the entire month (2 repeat infections, 3 first time infections).  In August we had 12 cases (3 were 2nd infections).  In July we had 18 cases (3 were  2nd infection), June saw 29 cases (3 were 2nd infections) and in May we managed 33 infections (3 were 2nd infections). I had expected a bit of an uptick in cases with the start of school but this has not occurred, at least in our small sample.

Trying to figure out what is occurring in terms of case rates at the County level is still a bit of a guessing game – most notably hampered by the fact that the overwhelming majority of cases are diagnosed via home testing and, by the County’s case definition, are not reportable. That notwithstanding, incidence case rates have declined steadily since mid July (Figure below).

In previous issues we have discussed how a calculated prevalence rate might be a more accurate representation of the true case frequency. Current prevalence rates are as low as they have been since May at 0.7 active cases per 100 individuals.

2. BA.5 Bivalent Booster Uptake

As most of you likely know, the FDA authorized the use of Moderna and Pfizer Bivalent Vaccines for a single additional booster dose at the end of August. This updated booster is to be given at least 2 months after completion of a primary series or the most recent booster dose of a monovalent (original) COVID-19 vaccine. The Pfizer booster is authorized for individuals 12 years of age and older. The Moderna for those 18 years and older.

According to the latest CDC data (link: https://covid.cdc.gov/covid-data-tracker/#vaccinations_vacc-people-additional-dose-totalpop), only 7.6 million individuals – about 3.5% of those eligible for the updated COVID booster – have received one. Of additional concern is that awareness of the new boosters is “modest” according to a recent survey (link: https://www.kff.org/coronavirus-covid-19/poll-finding/kff-covid-19-vaccine-monitor-september-2022/). One in five people surveyed have heard “nothing at all” about the new booster as compared to 17% who have heard “a lot.”

Personally, I’m pretty pumped (as Parker Schnabel would say – for my fellow Gold Rush fans out there – Discovery Channel Friday nights) about the new booster and am hopeful that it generates more specific and durable immunity than the prior boosters. Why would I feel this way?

Well, firstly, the current booster is matched with the dominant circulating strains as it contains an mRNA component from the BA.4 and BA.5 Omicron variants. The graphic below shows that these account for the overwhelming majority of variants isolated in the United States: BA.5 at 85% and BA.4 at 13%.

Additionally, this is one of the first times that we have not been vaccinating or boosting into the teeth of a case rise. Given such, the relatively slow uptake of the booster dose is less concerning as we do have the luxury of time, for once. With a general rule of thumb being that it takes about two weeks for the booster effect to take hold in our immune system, the continued decline in cases makes it less likely that one will be exposed to the virus soon after the booster dose – perhaps before it takes effect. 

I generally have been advising patients to strongly consider having the booster by the end of October – which is also a guideline for the seasonal influenza vaccine. While you can have both at the same time, it may be more prudent to separate the two. That way in the case of an unlikely, but possible, vaccine reaction – the cause will be apparent.

3. Blogs This Month

Our blog posts this and previous months can be found archived on our website at www.drbretsky.com/blog. This month we had two Blogs covering booster shots. One in the context of the seasonality of COVID (a trend which has clearly emerged) and the other structured as a Q&A session on the boosters itself.

Booster Shots and COVID Seasonality: https://drbretsky.com/9-september-2022-blog-post-new-booster-shot-heralds-covid-seasonality/

Booster Q&A: https://drbretsky.com/13-september-2022-blog-post-fall-2022-covid-boosters/

Our third blog covered more well-trod ground looking at incidence and prevalence rates of COVID-19 in Los Angeles:

https://drbretsky.com/14-september-2022-blog-post-mid-september-covid-case-numbers/ 

And out final monthly blogged looked at the idea that the US ‘follows’ the UK when it comes to COVID case rates (spoiler alert: it sort of does, but not always): https://drbretsky.com/28-september-2022-blog-post-following-the-uks-lead/ 

This final blog garnered some interesting Twitter reactions, namely critiques of the Zoe Health Study which is composed of self-selected participants who record COVID like symptoms into an app along with any COVID testing results.

4. On Patient Reviews

Patients who have seen us in the office recently will know that we have been actively seeking patient feedback about our services on rating sites, including Google, Facebook and Yelp. These have become increasingly important in quality metrics that measure the patient experience. We appreciate the time and effort that you have taken to post your experience.

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September 2022 Newsletter

September 2022 Newsletter

Welcome to the September 2022 Newsletter for Santa Monica Primary Care. In this issue, we are going to discuss COVID-19 prevalence in Los Angeles County and try to predict its future, in the context of the new bivalent booster and an inevitable Winter surge. We will also cover medical records sharing and ‘interoperability’ between electronic systems and healthcare providers.

 

COVID-19 in LA County and the Practice during August 2022

COVID-19 cases in our practice have begun to slow slightly – a trend consistent with that seen nationally and in Los Angeles County. In August we had 12 new cases (3 were 2nd infections)  with clusters at the beginning of the month (8/1-8/3), the middle (8/16-8/16) and the end (8/29-8/31). This is a somewhat different pattern than we had seen in July (18 cases, 3 were  2nd infection), June (29 cases, 3 were 2nd infections) and May (33 infections, 3 were 2nd infections) where cases accumulated at a steady clip of about one new case a day.

Trying to figure out what is occurring in terms of case rates at the County level is a bit more difficult. Firstly, LA County continues to have a significant lag in reporting with case numbers only current to 8/24/2022. Secondly, a significant proportion of positive tests will be from home testing which the County specifically does not include in their tabulations. Despite such, COVID-19 case rates for the month of August 2022 were the highest they have been in any pandemic for the month of August. For the week ending August 24th, 2022 set the high bar at 61.2 new daily cases per 100,000 population compared with 27.4 in 2021 and 18.4 in 2020. Current case rates are about twice as high currently as they were last year.

Given the difficulty in case ascertainment, another metric that can be considered is mortality rate. The mortality rate currently is 3 times what it was at the end of August 2021 (0.04 daily deaths per 100,000 population in 2021 versus 0.12 in 2022). Current mortality rates are about three times as high currently as they were last year.

Nationally, the BA.5 variant remains the overwhelmingly dominant circulating viral strain.. BA.5 now accounts for 88.7% of the variants isolated as opposed to 81.9% in July and 54% in June. Link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions 

 

BA.5 Bivalent Booster and Predicting the Future

On August 31st, the FDA authorized the use of Moderna and Pfizer Bivalent Vaccines for a single additional booster dose, to be given at least 2 months after completion of a primary series or the most recent booster dose of a monovalent (original) COVID-19 vaccine. It is important to note that the bivalent booster will contain genetic recipes for both the original COVID strain as well as BA.4 and BA.5. The Moderna bivalent vaccine is authorized as a single booster for those aged 18 years and above, and Pfizer is approved for those 12 and older.

The question moving forward is just how effective the new booster formulation will be – both in terms of boosting neutralizing antibody levels but, more critically, in preventing infection. While there have been no human studies of the bivalent vaccine going to trial, a study of an earlier BA.1 + ancestral strain booster (2nd booster) showed improved neutralizing antibody levels as compared to the monovalent (original). Antibody levels among those with no prior COVID infection were 2372 with the bivalent booster as compared to 1473 with the monovalent booster. It is interesting to see that these levels are quite a bit lower than what we have been seeing in the practice, with most individuals having levels between 3000-6000 after a primary series + one or two boosters. Whether or not these neutralizing antibodies are of sufficient quantity and specificity to prevent infection remains to be seen.

The future is not too difficult to predict, as seen from the prevalence chart below. I think we have every reason to expect another Winter surge – most likely beginning mid December and lasting through January.

Blogs This Month

Our blog posts this month included a two part series on changes at the CDC. There is also a more lengthy essay on Monkeypox (which appears to be decreasing in frequency, at least in Los Angeles).

Structural Changes at the CDC (Parts 1 & 2):

https://drbretsky.com/29-august-2022-blog-post-major-changes-in-cdc-announced-part-1-of-2/

https://drbretsky.com/30-august-2022-blog-post-major-changes-in-cdc-announced-part-2-of-2/ 

 

Monkeypox:

https://drbretsky.com/3-august-2022-essay-everything-you-wanted-to-know-about-monkeypox-but-were-afraid-to-ask/

 

On Medical Record Sharing and Interoperability

One question I have gotten a lot this month has been about medical record sharing and, specifically, if our office receives outside consultation notes, imaging and studies. The short answer is – sometimes (even if you specifically request it from the consulting physician) but it is a process that we are working to improve.

Traditionally, consulting physicians or specialists have communicated directly with a patient’s primary care provider in the form of a consult ‘note’. Many of the more experienced specialists will not only send their clinic / chart note but also a cover letter summarizing their findings and recommendations. Sadly, with the advent of Electronic Medical Records, this tradition has largely been lost. One would think that notes would be automatically routed to the referring or primary care physician but this too does not always happen.

The term ‘interoperability’ is used as a catchall phrase by health insurers and EMR vendors to describe a “system architecture that allows for the electronic sharing of patient information between different EHR systems and healthcare providers.” The idea being that information passes between the doctors providing patient care seamlessly. Responsibility for such was intended to fall to health insurance companies, permitting data exchange should an individual change insurance. However, the current administration has decided to defer enforcement of this responsibility citing the COVID-19 pandemic (link, if you are fascinated by this: https://www.cms.gov/blog/interoperability-and-connected-health-care-system).

What we have done as a practice is begun to set up processes to physically go and look for our patients’ information. One such mechanism comes through our collaboration with Aledade (www.aledade.com) which we have discussed in previous newsletters. In addition to their quality of care metrics tracking, Aledade software includes an interface that alerts us as to any hospitalization or Emergency Department visit, prompting us to follow-up on that event.

One way that patients can further help with interoperability is to ensure that on their CareEverywhere or MyChart account that Dr. Bretsky is listed as their primary care provider. We have started a process in the Cedars / Providence / UCLA systems of adding our office contact information manually so that reports are automatically sent to us. But patients themselves can double check that we are listed as Primary Care Providers (often these listings are outdated or include other providers, such as OB/GYN).

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August Newsletter

August 2022 Newsletter

Welcome to the August 2022 Newsletter for Santa Monica Primary Care. In this issue, we are going to discuss case rates in Los Angeles County and why our Health Department decided against resuming an indoor mask mandate. We will also discuss Paxlovid rebound in the context of President Biden’s SARS-CoV-2 experience.

1. COVID-19 in the US and LA County during July 2022

COVID-19 cases in our practice have continued at a steady clip of about one new case a day – which has been consistent over the past three months.

 

Nationally, the BA.5 variant has overwhelmed the  original Omicron BA.1 and BA.2 variants as well as the BA.2.12.1 and BA.4 sublineages. BA.5 now accounts for 81.9% of the variants seen as compared to 54% of the total last month. Link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions 

 

Cases in Los Angeles County after our huge Omicron surge in December and January were lowest the week ending March 22nd when they were at 5.8 new daily cases per 100,000 population (note viral containment is generally defined as under 1 new daily case per 100,000). They have risen steadily since that time and now stand at 59.3 cases/100,000. Note the slow rise as compared with the sharp peak of Omicron.

Similarly, prevalence (the proportion of active cases per 100 individuals) has steadily increased over that time period.  While down as low as 0.05% in late March, the most recent prevalence estimate is 9.6%. This has risen from 8.2% the week prior.

The Health Department based their decision to forego an indoor masking mandate as hospitalizations seem to have plateaued (link: http://dashboard.publichealth.lacounty.gov/covid19_surveillance_dashboard/).

We are not seeing a reduction in incidence case rates or prevalence at this point, either in the County or in the practice as a whole

 

 

2. Paxlovid Rebound

We have covered Paxlovid rebound in prior Newsletters and, as mentioned before, Paxlovid rebound has continued to be a thorny issue. To see it occur with President Biden was not a complete surprise. In our aggregate experience, 10 of the 35 patients (28%) we have treated with Paxlovid have experienced a clinically apparent rebound.   

 

Most national estimates discuss a Paxlovid rebound rate between 10% and 40%. While patients taking Paxlovid feel better faster and the rebound infection is typically milder than the initial symptoms, it nevertheless is something to consider before starting treatment.

 

 

3. Blogs This Month

Our blog posts this month focused once again on our ongoing COVID-19 pandemic, which has changed in contour since we first began covering it in March of 2020. We specifically discussed the absurdities of the CDC’s 5 day isolation guidance in “Do As I Say, Not As I Do”.  We also covered the population dynamics of the virus as well as what some call the inevitability of acquiring the infection.

 

On The CDC ‘5 Day Rule’:

https://drbretsky.com/28-july-2022-blog-post-do-as-i-say-not-as-i-do-and-the-cdc-5-day-rule/ 

 

On Population Prevalence and the ‘Luck’ of COVID Acquisition:

https://drbretsky.com/27-july-2022-blog-post-population-prevalence-and-the-luck-of-covid-acquisition/ 

 

On The Return of Masking, Summer 2022 Edition:

https://drbretsky.com/25-july-2022-blog-post-on-the-return-of-masking-summer-2022-edition/

 

4. August’s Epidemiology Definitions

Clinical Trial: A synonym for an epidemiologic experiment which is typically conducted with the aim of evaluating which treatment for a disease is better. 

 

Placebo: A comparison group in a clinical trial intended to have no biologic effect outside of the roffer of treatment itself. The term is from the Latin “I shall please” and placebo pills typically contain sugar or other inert ingredients.

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JULY Newsletter

July 2022 Newsletter

Welcome to the July 2022 Newsletter for Santa Monica Primary Care. In this issue, what’s old is new again (unfortunately).  We are going to revisit case rates in Los Angeles County and why Health Department counts are undoubtedly an underestimate. We will also discuss SARS-CoV-2 antibody levels and Evushield, an exciting new pre-COVID exposure preventive tool.

  1. COVID-19 in the Practice during May and June 2022

COVID-19 cases in our practice continued at a steady clip of about one new case a day. In total, we recorded 24 cases of SARS-CoV-2 infection, two of which were second infections. This was down from May when we had 33 cases. 

Nationally, the original Omicron BA.1 and BA.2 variants have given way to the BA.5 (54% of total) and BA.4 (16.5%) sublineages. A third, BA.2.12.1 accounts for about 27% of total cases observed.  As these new subvariants emerge, there exists the possibility that immunologic protection from a prior variant may not protect against a new variant. In fact, there is preliminary evidence that prior infection with BA.1 may not protect against BA.4 or BA.5. Link: https://covid.cdc.gov/covid-data-tracker/#variant-proportions 

There is not yet any evidence that either BA.4 or BA.5 lead to more severe illness as compared to other Omicron strains. In our experience, the currently circulating variants may even be a bit less severe.  We categorized 17 of our 24 cases (71%) in June as ‘mild’ as opposed to 17 of our 33 cases (51%) in May.

  1. COVID-19 in the Community

With widespread availability of home testing combined with the fact that home test results are no longer reportable to the County of Los Angeles, officially published numbers should be viewed as a significant underestimate of the true impact of infection. 

One useful active surveillance tool that might give some insight into community rates are data from Santa Monica Malibu School district which performed weekly PCR testing on students. With the school year ending, the final week of testing was May 31st – June 5th showing a slight decline in prevalence from 1.45% to 1.36% (note that no testing was done in the high school that week).

  1. Paxlovid Rebounds

Dr. Bretsky was one of the first physicians nationally to begin to discuss the impact of Paxlovid rebound on the duration, trajectory and transmission patterns of SARS-CoV-2 being quoted in a widely publicized Washington Post article at the end of April 2022 (link: https://www.washingtonpost.com/health/2022/04/27/paxlovid-second-case-covid/).

Paxlovid rebound has continued to be a thorny issue as 50% of those treated with Paxlovid during the month of June experienced a rebound case (5 rebounds among 10 patients treated). Most national estimates discuss a Paxlovid rebound rate between 10% and 40%. While patients taking Paxlovid feel better faster and the rebound infection is typically milder than the initial symptoms, it nevertheless is something to consider. As I tell patients, Paxlovid can turn a 5-7 day illness and isolation into a 3 week extravaganza.

  1. Blogs This Month

Our blog posts this month focused on the public health threat posed to women through the overturning of Roe v. Wade. We also highlighted how maternal mortality rates in the United States showed statistically significant increases during the last two years of the Trump Administration as states began rolling back pregnancy termination access. There are two major factors that significantly modify the risk of maternal mortality: 1. Access to contraception and 2. Access to safe pregnancy termination. This makes it straightforward to protect but also incredibly easy to dismantle.

On SCOTUS and the Dismantling of Women’s Health:  https://drbretsky.com/29june-2022-blog-post-on-scotus-an-the-dismantling-of-womens-health/

Overturning Roe v. Wade: https://drbretsky.com/24-june-2022-blog-post-overturning-roe-v-wade/

With the Euro sinking to a 2 decades low against the dollar, and more people electing to travel to Europe this summer, a COVID update for the continent seemed timely.

On COVID in Europe: https://drbretsky.com/22-june-2022-blog-on-covid-in-europe/

  1. July’s Epidemiology Definition

Odds Ratio: A statistic that quantifies the strength of association between two events, A and B or the “odds” of A in the presence of B. An odds ratio of one (1) means that A and B are independent. If the odds ratio is greater than one then A and B are correlated such that the presence of B raises the likelihood of A. If the odds ratio is less than one then the presence of one even reduces the odds of the other event.

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