As the COVID-19 pandemic continues, physicians are faced with many questions from their patients about vaccines, safety measures, risks of new variants, and the efficacy of new treatments. Robert M. Wachter, MD, member of The Doctors Company’s Board of Governors, renowned expert on COVID-19, and Professor and Chair of the Department of Medicine at the University of California, San Francisco, recently shared his thoughts on answers to some of the most common questions patients are asking healthcare providers.
We're all having to negotiate this weird new normal. I respect people's personal choices. I think it would not be unreasonable to say, “I will go on trips that are mandatory, but for a trip that's more elective, I'm going to wait until I'm really confident that the level of COVID-19 is lower than it is now.” The planes are quite safe. The level of air filtration on airplanes is better than in most stores and workplaces. Most of a plane flight involves traveling in a very well-ventilated indoor space with near-universal masking, which feels quite safe. And then, at some point, when people take their masks off to eat, it turns into a flying restaurant. When I fly, I do everything I can to keep my mask on for nearly the entire flight. During the peak of the Omicron surge, I’ve curtained my travel to only truly necessary trips, but anticipate picking back up again as the surge recedes.
As with travel, during the height of the Omicron surge, I’ve stopped eating in indoor restaurants – it just seems too risky to be in a crowd of people who might be infected (even if they feel well) with masks off. I'm still perfectly comfortable eating in outdoor restaurants. As this surge recedes, I’m confident that I’ll again be comfortable with indoor dining and other indoor activities. The question will be when to wear a mask, and that’s one that individuals may have to answer for themselves (assuming that it’s not dictated by local policy). In general, once the surge recedes, someone who is fully vaccinated and boosted will have a relatively low likelihood of catching the virus, and a benign prognosis if they do. And, over time, there will be increasing availability of medications (particularly the antiviral pill Paxlovid) that can lower the probability of a severe case even in high risk people who get a case of Covid. So I suspect that all of us will experience much more freedom in the spring as this surge goes away.
Treatment has gotten better. We now know that for someone who is sick enough to be in the hospital, if you give them corticosteroids and other immune modulator drugs, we can decrease the chances they'll get super sick and die. Some will get very sick and die, unfortunately, but it's a lower chance. The big recent breakthrough was the report from Pfizer about a new oral medication for people who were unvaccinated or who were at high risk of a bad outcome, a drug called Paxlovid. For older people or people with other medical comorbidities, taking the pill for five days decreased the chances that they would need to be hospitalized or would die by 90 percent. It looks like the side-effect profile is benign, although there are a fair number of drug-drug interactions to be aware of. Whether someone who’s vaccinated will be eligible for that medicine and will want to take it is an open question – right now it is in very short supply, which will require that it’s use be rationed, at least at first.
You get some immunity from infection. The problem is that it's heterogeneous, meaning it's a little bit unpredictable in some people. It seems to be reasonably strong immunity in some people. It seems to be less strong in others. But in both cases, the immunity wanes over time, and it is wise to be vaccinated. A person who has had full vaccination plus a prior infection has a very high level of immunity against reinfection and particularly against a severe case of Covid.
The vaccine markedly lowers the probability that you will get infected, that you'll get really sick, and that you will die. We now know that a vaccinated person can still catch the virus and spread it to others, but the data says that the probability of that is lower than it would be if you were unvaccinated. There are no vaccines that are 100 percent perfect, but these vaccines are extraordinarily good.
People say, “I don't mind getting a mild case of COVID-19.” For some people, it really is mild, like a cold. For others, it's like they were run over by a bus. About 5-10 percent of people with mild cases of COVID-19 continue to feel terrible a month out—so-called long COVID-19. Some people feel terrible a year out.
So, you can't let the perfect be the enemy of the good. And these vaccines are incredibly good, better than our wildest dreams.