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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