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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