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ALICANTE, SPAIN – Tourists and locals cool off at a crowded El Postiguet Beach during a summer day. Despite summer, there is a surge in Covid, which can be transmitted outdoors, or indoors, as people seek air conditioning (Photo by Marcos del Mazo\/LightRocket via Getty Images)<\/p>\n
LightRocket via Getty Images<\/p>\n
With this summer\u2019s surge in COVID-19 infections underway, there are some new things to be aware of.<\/p>\n
First is what Michael Hoerger, Ph.D., a Covid mitigation and forecasting expert at Tulane University, describes as \u201cbluewashing,\u201d with the CDC downgrading the colors and rankings on its Covid maps. As he noted, \u201cMuch of what was Very High is now “High.” What was High is now “Moderate” or “Low.” Low is “Very Low.” Hoerger continues, \u201cThis time, there was no alert and no explanation. Major changes were confined to COVlD, not Influenza A, and not RSV. The CDC made these questionable changes in the middle of rising transmission across most of the country; 15 states already have COVlD outbreaks, and others may soon join the ranks. These are serious ethics concerns that warrant investigative journalism.\u201d Hoerger further notes delayed reporting at High\/Very High levels from some monitoring sites and that the CDC does not take this into consideration. His Pandemic Mitigation Collaborative\u2019s PMC Dashboard is my go-to for up to date information on prevalence and risks. Texas is the biggest hot spot now, followed by Alaska, Hawaii, and California. There are at least 24 outbreaks already.<\/p>\n
Hoerger expects that, \u201cif transmission follows historical patterns, it will peak around Labor Day and then again on New Year\u2019s Eve.<\/p>\n
Vaccines<\/p>\n
Just as with annual changes to flu vaccines, the composition of the COVID-19 vaccine needs to change as new variant strains emerge. This year, the target will be the XFG variant, still a descendant of the JN.1 lineage, as was last year\u2019s, which targeted the LP.8.1 variant of the SARS-CoV-2 virus.<\/p>\n
It is unclear when the FDA will authorize the updated vaccine. They have not responded to my inquiry.<\/p>\n
Who Should Get The COVID-19 Vaccine?<\/p>\n
Before Robert F. Kennedy, Jr was appointed Secretary of Health, the vaccine was recommended for anyone older than 6 months. Kennedy and his appointees opposed the vaccines for healthy children and pregnant women, bypassing traditional science-based review from the CDC\u2019s Advisory Committee on Immunization Practices. After considerable backlash from the scientific and medical community, Kennedy downgraded the recommendation to \u201cshared decision making\u201d for those younger than 65.<\/p>\n
Pregnant women have a significantly higher risk of complications including preterm delivery, respiratory failure, and death. Despite his appointing two anti-vax physicians<\/a> to the ACIP, the American College of Obstetricians and Gynecologists recommends pregnant women be vaccinated to prevent Covid infections.<\/p>\n The American Academy of Pediatrics has recommendations for children here<\/a>, specifically recommending vaccination for kids with asthma, sickle cell, diabetes, obesity, epilepsy, among other underlying diseases, as well as those with family members at risk for severe disease, and anyone whose parent desires their protection from infection. <\/p>\n What To Do If You Suspect Infection<\/p>\n First, have a low threshold for testing. Many infections now are mild and could be easily dismissed as allergies, a summer cold, or jet lag. If the first test is negative, I would repeat it in 24-36 hours. This is important because the antiviral Paxlovid is most effective taken early, as is metformin.<\/p>\n Medicines To Reduce Illness Or Prevent Long CovidPaxlovid<\/p>\n In those at high risk and who are unvaccinated, \u201cPaxlovid significantly reduced the proportion of people with Covid-19 related hospitalization or death\u201d by 88% compared to placebo<\/a>.<\/p>\n But for those who are vaccinated, there is no benefit<\/a> in reducing hospitalization or death, even among the elderly. UpToDate, a medical treatment guide, recommends treatment for those older than 75 or with significant underlying disease<\/a>. Benefit was limited to those at high risk and was predominantly a small reduction in illness duration.<\/p>\n A recent study \u2014 a small but well-done, double-blind, randomised placebo-controlled trial showed patients who received Paxlovid (nirmatrelvir\u2013ritonavir) had a significantly lower risk <\/a>of being symptomatic at 3 months (26%) compared with those receiving placebo (43%).<\/p>\n The cost of Paxlovid is $1400-$1500 with some patient assistance programs available.<\/p>\n Metformin<\/p>\n Curiously, the UpToDate authors do not recommend metformin. A recent meta-analysis<\/a> concluded that the drug provided \u201cmodest benefit in reducing hospitalisation, ED visits, or mortality\u201d but that the findings were inconclusive.<\/p>\n I\u2019ve long recommended metformin<\/a> to help prevent long Covid, largely based on Carolyn Bramante\u2019s studies. Her first study showed a 41% reduction in the incidence of long Covid, compared with placebo, when started early.<\/p>\n In the May 2024 \u201cCOVID-OUT\u201d study, Bramante\u2019s group showed the SARS-CoV-2 viral load was cut 3.6-fold with metformin<\/a> compared to placebo. The odds of severe COVID-19 were reduced by 55% and of long COVID by 65% if metformin was started less than four days from symptom onset. The RECOVER trial extended the finding to patients with diabetes, and showed a 13% to 21% lower incidence of long COVID or death.<\/p>\n They also found that metformin reduces viral load and pro-inflammatory molecules<\/a> that contribute to clotting in Covid infections.<\/p>\n Metformin is a pretty benign drug\u2014its main side effects are GI upset, and it is better tolerated when titrated up. It is relatively inexpensive, $10-30 for a 60-day supply (500 mg dose<\/a>).<\/p>\n The main problem I\u2019ve encountered is hearing that providers are refusing the request for a 2-week course of metformin, because \u201cit\u2019s just for diabetes.\u201d<\/p>\n Azelastine\/Antihistamines<\/p>\n Azelastine is a nasal antihistamine spray. In a 450-patient randomized, controlled, double-blind trial, it significantly lowered the incidence of subsequent COVID-19 infection<\/a> to (2.2%) compared with the placebo group (6.7%). It also reduced the risk of rhinovirus (cold) infections. It\u2019s thought to work by blocking the viral receptor in the nose.<\/p>\n In preliminary data from the University of Florida, researchers found diphenhydramine (Benadryl), hydroxyzine (Atarax), and azelastine<\/a> to inhibit coronavirus infection of cells. Fexofenadine (Allegra) and loratadine (Zyrtec) are similar H1 receptor blockers, but there is not data yet as to their efficacy.<\/p>\n Famotidine, an H2 blocker, reduces the severity<\/a> and mortality of Covid infections in some studies.<\/p>\n Ensitrelvir\/Post-exposure prophylaxis<\/p>\n