Respiratory Viruses in Winter 2023-2024: The Public Health Burden of COVID-19
In this video roundtable episode, Jaspal Singh, MD, MHA, MHS, interviews Lisa Davidson, MD, Katie Passaretti, MD, and Amina Ahmed, MD, about the public health burden of COVID-19, including virus mutation, current booster vaccination recommendations, antiviral treatments, and treatments in the pipeline for different age groups. This is part two of a three-part series on respiratory viruses in winter 2023 to 2024.
For more COVID-19 content, visit the disease state hub.
Watch part one of the three-part series on respiratory viruses in winter 2023 to 2024 here.
Watch part three of the three-part series on respiratory viruses in winter 2023 to 2024 here.
TRANSCRIPTION:
Jaspal Singh:
Hi, everybody. Welcome to Consultant 60. I'm Jaspal Singh, your host for today's episode on infectious disease updates. This is part two of our three-part series on infectious diseases going into winter 2023 and 2024. Next, this segment is about COVID-19 and the update. Yes, it's 2023 and we're talking about COVID-19. And here we are, but there's obviously some very important updates and some things to keep in mind. So, with us today, we have three esteemed guests again, Drs Passaretti, Davidson and Ahmed. And Katie, I'll start with you. Introduce yourself, if you don't mind.
Katie Passaretti:
Sure. Katie Passaretti. I'm Vice President and Chief Epidemiologist for Atrium Health and a clinical professor in infectious diseases for Wake Forest University.
Jaspal Singh:
Dr Davidson?
Lisa Davidson:
Hi, I am Lisa Davidson. I'm the medical director for antimicrobial stewardship. I'm also the chief quality officer for adult medical specialties in Atrium Health, Greater Charlotte market. And I'm a clinical associate professor at the Wake Forest University School of Medicine.
Jaspal Singh:
Great. Dr Ahmed?
Amina Ahmed:
Thank you. Hi, I'm Amina Ahmed. I'm the Medical Director for Pediatric Infectious Disease and Immunology, and a hospital epidemiologist at Levine Children's and clinical professor at Wake Forest University.
Jaspal Singh:
Thank you so much for updating us. I know we've talked a ton about COVID in the past, and I don't think I can talk about it anymore, but here we are. But the good thing is I don't think anyone's talked more than Katie. So I'm going to start with you, Katie. I'm sure you want to update our audience about some important updates. And where are we at in terms of public health burden? I just spent the weekend in the ICU and we did have some COVID, right? We've had some recent deaths and some pretty sick people. So, where are we now?
Katie Passaretti:
Yeah, COVID is here to stay. I think we've well established that over the past couple of years. Luckily we have fully entered that endemic state where COVID is constantly present, and we'll see increases and decreases in our community and in our hospitals. But those increases, especially on the hospital side with severe illness, ICUs being overwhelmed is to a much lower extent. So we've recently, in our area and many areas of the country, seen a very significant rise in COVID cases in the community, wastewater surveillance metrics and whatnot.
But that's not translating into tremendous increases in hospitalization. So just for context, we're seeing maybe 5 to 10% of the hospitalizations that we saw when Omicron first started to hit and relatively few ICU stays. So certainly in our most at risk patients, our most vulnerable patients, we can still see severe disease, but it's become more manageable, especially if we leverage the tools that we have out there to keep ourselves safe, whether it's vaccines in the right setting, masks, that kind of stuff to layer on layers of protection.
Jaspal Singh:
That's great. Dr Davidson, talk about some of the newer strains or what's going around both regionally as well as potentially internationally, if you don't mind.
Lisa Davidson:
So, I think the strains here, the sort of news about them is that they're all still Omicron sub variants like grandchildren or great-grandchildren of the original Omicron strains. So when it comes to vaccine efficacy or vaccine targeting or any treatment targeting, we haven't had a big antigenic shift that is requiring us to sort of change our strategies or change our medications.
And as long as you've seen Omicron, it's very few and far between, although there is a certain percentage of patients that have never had COVID. If you've seen or you've had an infection probably in the last year you've experienced those strains. So I guess that's good-ish news in that we're not dealing with a new variant or a whole new strain type. And so that gives us maybe a little bit more breathing room.
Jaspal Singh:
That's helpful. Talk to us about the new vaccinations, of the new boosters, I should say, about more protective or where are they in that space?
Lisa Davidson:
So, I would say, and others can chime in here, first of all, this latest vaccine, it's a single strain. So the last go around we had two strains, but this one is just a single strain based on the sort of most recent Omicron variants that were circulating over the summer. So single strain, good activity, probably not quite as high as our original vaccines. Those were like in the 90%, I think the last time I looked this was 60 to 70%. Katie's going to sort of tell me around that if I'm wrong.
So a lot of benefit, and again, what we've really seen in one vaccine study over the next is just a huge amount of benefit preventing ED visits, hospitalizations, and deaths. So when I talk to people about it, I'm always saying it may not prevent you from getting COVID, but it's certainly going to lessen your symptoms of COVID. But more importantly, especially in the highly at-risk population, it's going to prevent the likelihood of you being hospitalized in the ICU or dying.
Jaspal Singh:
That's great. Amina, anything to add in addition to that, and especially in the pediatric world, what's going on there?
Amina Ahmed:
So in the pediatric world, what happened, what we noticed was when the vaccines became available for adolescents, everyone was on board, lots of kids getting vaccinated. And then for the next iteration, which was the 5 to 11 year old that seemed not as many were vaccinated. And then when we got down to the young kids, the ones that we were all worried about, it seemed even less of an uptake. And I guess I want to remind parents it's not just about doing good for the community, but there is some truth to what happens with the dynamics of population immunity when you've got vaccines and natural immunity and you need them both to build up that herd immunity to a degree. And at some point if that does drop a critical level, that's when that emerging variant goes wild. And then we're back to square one in terms of severity.
And I think it's also important to remember that vaccines do prevent MISC, which is multisystem inflammatory syndrome in children, which I think we've forgotten about. We haven't seen cases, we saw the most number of cases at North Carolina in 2020 to 2022 and then all of a sudden we haven't seen very much at all. And it's because we've got this level of immunity and vaccinating your child is going to prevent them from getting COVID, which most people think, oh is a mild illness in children, but it can prevent this multisystem inflammatory syndrome, which is a severe complication and has more heart complications associated with it than any rates that have been cited for vaccines in the past.
Jaspal Singh:
That's a great reminder. I completely, honestly myself, I don't think about it actually, to be honest with you. Because you're right, we've forgotten about this inflammatory condition and thanks for that important reminder about that. Katie, anything else to add on that conversation?
Katie Passaretti:
Yeah, I was just going to say the CDC for flu vaccine has a campaign going where they're trying to educate on what you expect from a vaccine generally. So the campaign is From Wild to Mild, so just reiterating that the importance of vaccines is to really bring down that level of severe disease, keep our hospitals running, keep people from dying and level setting expectations on what vaccines do, what the goal of vaccines are. And then the only other thing I wanted to add, so that applies to COVID flu, really all of them, our goal is to keep people alive and if they get sick, it's relatively short-lived and out of the hospital.
That's the public health goal, that's the physician goal. The other thing I just wanted to comment on, there's more and more data suggesting that vaccines for COVID not only do a good job of continuing to prevent severe illness but also impact your risk of long COVID, which does tend to be more prevalent in 35 to 50, 60 year olds, that mid-age population and while it's not ending you up in the hospital, certainly has impact on quality of life, economic impact, all that kind of stuff. So I would just say increasing body of evidence that vaccines can be protective there and just know that going into your decision on vaccines if you're otherwise low risk for severe illness.
Jaspal Singh:
That's a great point actually, it's funny that you mentioned that because literally I was just talking to my colleagues around the country who were in my discipline and a couple of them actually I was surprised, healthy, got this COVID and not hospitalized, but just really took them weeks to months to really get back to even close to their baseline level of function and these were relatively healthy people. So I think none of them have gotten the booster recently, so I was like, that was really interesting. They thought they were out of this and it's just a reminder for us. I'm going to get mine a soon that we can get it. That's fantastic.
Katie Passaretti:
Can I say one other thing? Yeah, the other thing just to level set, we've been in this revolving door of COVID vaccine recommendations and it's been super confusing, but we are settling into, it's going to be a yearly COVID and flu vaccine. The COVID vaccine will get updated to match the most current, because respiratory viruses, whether it's flu, COVID, any of the above, continue to evolve over time to survive. That's what they want to do. Anticipate settling into an annual COVID and flu shot as we head into what we anticipate to be peak season during the fall and winter months.
Jaspal Singh:
That's very helpful. Anything different? Lisa, you mentioned about the virus itself has sorted not changed in terms of overall antigenicity. Talk about the antiviral treatments, anything different at all or anything coming on the pipeline that we need to be aware of?
Lisa Davidson:
So a couple things that really changed, I would say from where we were in 2022, so we phased out the use of monoclonal antibodies. Those were great and they did a great job but not a sustainable model for treatment. So we're really left with outpatient treatment with two oral antivirals. So Paxlovid and molnupiravir both have data to show benefits on decreasing time to symptom improvement, ED visits and hospitalizations. There's probably a bit of a stronger data with Paxlovid and that tends to be the treatment of choice. And the only contraindications to Paxlovid would be pediatrics, so age less than 12, and then drug drug interactions. And even a drug drug interaction, I usually counsel patients we should look at it, but it's not an absolute contraindication. With Paxlovid, the most common side effects are GI upset or a distaste in the mouth and those resolved after stopping the medication.
So a couple of things that changed with the labeling previously was if for Paxlovid was if you had a high risk medical condition or you were over the age of 65 and the labeling actually just changed to say 50 years and older. I'm not exactly sure why we had a label change, but that's just something to be aware of. Usually when I am counseling on shared decision making for Paxlovid treatment, it really depends on the patient, their risk, the risk factor, people around them at home. So for an otherwise healthy adult, it might really not make an improvement, but certainly people with underlying comorbidities or immunocompromised or someone who's immunocompromised at home, it would be a viable treatment option. Both have to be given in the first five days of illness still.
And really not much has changed on the inpatient side at this point in time. We're dealing with the same drugs. The other thing I will say is that for almost all the inpatient and outpatient drugs in the adult population, they're no longer under an emergency use authorization because the public health emergency is over. So all that EUA documentation, et cetera, et cetera, is no longer really an issue.
I will say the negative side of that is that we're about to go into the final phases of using up the national supply. So that's probably going to expire in the next several weeks. And then once that happens, we're going to be charging people as we would for any other drug. So that's the mystery right now is how much is going to be covered, how much is not going to be covered for treatment. Vaccine should still be covered but for the treatment part of, it's a big mystery right now as to how much is going to be covered and how much is not going to be covered.
Jaspal Singh:
That's super helpful to know, actually. I did not realize that a lot of my patients will be probably calling and we'll have to figure out where to get them cheaper. Amina, anything else to add on that?
Amina Ahmed:
No, there are some oral drugs that are in the pipeline. There's an oral version of remdesivir, and it is manufactured by Gilead. That's going to be trialed and it's an option for kids under 12 because there's not many options for kids under 12, mostly right now for immunocompromised, but then ultimately, hopefully for healthy patients as well.
Jaspal Singh:
Well, that was super helpful. So it sounds like COVID is sort of we're endemic. We still are going to have a lot of patients come through with, obviously not the same volume that we had early in the pandemic, but still something to be vigilant about and just be aware of, especially in our vulnerable populations.
The Omicron variants are still there. It hasn't changed tremendously and the drugs are still fairly consistent now. We have, I think, sort of a steady rhythm you might say of how to approach some of these infections now at this junction, but still vaccination prevention, maintaining a healthy immune system, all the usual things that we'd recommend for healthy lifestyle are important. But also the booster of vaccination, even though it's not perfect, it's still effective overall from a public health perspective and from an individual perspective can be extremely helpful.
And I think we are some interesting therapies coming on the pipeline, but we'll have to watch out for that for different age groups and different susceptibilities. Looking forward to hearing more and I'm sure we'll revisit this again next year. All right. On behalf of Consultant 360, I want to thank our three guests, Drs. Passaretti, Davidson, and Ahmed for being with us today to talk about the COVID-19 update.
Amina Ahmed:
Thank you.