We can't pretend our way out of an epidemic. Paxlovid has tremendous promise. Problem is, there are more cases in one day than Paxlovid courses expected during this surge.
We need ethical means of allotting these courses for maximal benefit. Otherwise, it's 1st come, 1st served🧵
Headlines say the US bought 10 million courses. These won't arrive until July. The total allotted in January and December will be fewer than the almost 500,000 cases the US is recording a day
NY State reported 85K new cases yesterday. NY state currently has 3,180 courses, that's not for one day, that's total currently allotted. full stop.
DC reports over 2000/day on average. It has 40 doses allotted.
There just aren't the doses for anyone who is unvaccinated or even anyone unvaccinated with a risk factor to receive Paxlovid. We can't pretend there are or we won't have any doses. It needs to be strategically prioritized.
Paxlovid can treat those 12 and older but we don't have enough doses for everyone.
Even if doses are given just to the unvaccinated: 29% of those 12 and older are unvaccinated.
Most US adults have at least 1 COVID risk factor. 70% of US adults are overweight (one risk factor).
About 3% of US adults are severely immunocompromised and cannot respond to vaccines fully, even when vaccinated. It seems worth protecting those most at risk, especially when monoclonal antibodies are limited, is crucial.
Paxlovid guidelines need to look at the risk associated with each risk factor.
Not all risk factors are equal. Age and Down syndrome stand out. They create more risk than other risk factors (hypertension, renal disease, lung disease).
** courses, not doses
Here is a look at cause specific hazard ratios after vaccination, the highest risk groups:
Down syndrome (12.7 fold)
Kidney transplantation (8.1-fold)
Sickle cell disease (7.7-fold), bmj.com/content/bmj/37…
By not making any decisions, states and the federal government are making a decision. Paxlovid ends up being first come, first served, rewarding those who have the best access to medical care.
Clinicians have to focus on and advocate for the patient in front of them. In a public health crisis and a resource limited setting, it can't be just about the patient right here, right now. Critical resources need to be shared effectively. US healthcare is not used to this.
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The criteria for prescription of Paxlovid are starkly different in different geographic areas and between public and private health systems.
This is a huge equity issue.
First come, first service apparently.
Paxlovid will run out soon.
NY State guidelines allow for Paxlovid for vaccinated individuals under 65 and 2 risk factors
NY City public health system only has the med for
immunocompromised or over 65, unvaccinated, with risk factors
This prioritizes those with private doctors and private pharmacies
The US state of Maryland has 960 courses. The guidelines would mean with almost 9000 cases a day that there would be enough eligible persons to use up the supply in one day.
The granddaddy of all - Ebola - is often mistaken for malaria, sometimes cholera or the flu
It spread for months in West Africa undiagnosed before one salient symptom was noticed - hiccups - by someone who knew Ebola
Ebola starts off mild
It's just a sudden fever. "It must be malaria"
Symptoms are "dry" - maybe a cough, headache, fatigue
Wet symptoms may take a week to develop - lots of watery diarrhea, vomiting.
Viral loads climb with illness and virus spreads more easily with wet symptoms
Most Ebola patients do not have heavy bleeding and never like the movies
Heavy bleeding with miscarriage or delivery, exposing midwives and other attendants, is common
Bruising or bleeding with IV's also happens
Bleeding zombies in the movies, not so much ncbi.nlm.nih.gov/pmc/articles/P…
It's not chasing down the few with no past infection or vaccination
Most have been infected or vaccinated in South Africa and worldwide
To spread this fast, this variant has been infecting those with some immunity
This changes how we quantify its risk.
It is a bit of the tortoise and the hare.
Variants that quickly infect in naive populations are like the hare. High R0
Variants that keep chugging along despite immunity may be the tortoise. High Immune Escape
Tortoise can win in the end
A bit of terminology
R0: # 2ndary infections per initial infection in a naive population
Intrinsic R0 no longer alone determines spread as the world is no longer naive to COVID
Rt or Reffective describes 2ndary infections in real time in an outbreak w/immunity, behavior change
In August, an 80 year old man woke up to find a bat on his neck. Bat tested positive for rabies. The man reportedly refused the vaccine. He died of rabies. First death in Illinois from rabies since 1954. dph.illinois.gov/news/illinois-…
So far this year, 30 bats have tested positive for rabies in Illinois. More than 1,000 bats are tested for rabies each year in Illinois due to a possible exposure. Approximately 3% of tested bats are positive for rabies.
So what is post-exposure prophylaxis for rabies?
- Clean wound with soap and water (or povidine-iodine)
- Immunoglobulin if never vaccinated for rabies
- 4 doses (immediately, then days 3, 7, 14)
Starting in September, Germany will offer another dose of Pfizer or Moderna to older people, residents of care homes, and people with compromised immune systems — and also to anyone who was already fully vaccinated with the 2-dose AZ or single-dose J&J nytimes.com/2021/08/02/wor…
HIV made the news because yet another vaccine failed. The real story is the impact of COVID on HIV and in turn on COVID. Roll out of a new med worldwide, dolutegravir, delayed. Many missed appointments, refills, doses. Others weren't diagnosed.
This impacts not just HIV but COVID
The cascade of HIV care - learning diagnosis, starting treatment, returning for appointments and viral load testing, adherence, HIV viral suppression - has had interruptions over the past 1.5 years worldwide.
Worldwide we have seen drop offs in service delivery along this cascade of care. theglobalfight.org/covid-aids-tb-…
This means people are missing their diagnosis, their meds, their control of the virus, and the chance to be healthy and also non-infectious