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Description

With lots of COVID treatments now available, how do you know which one, if any, is right for you? Andy found himself just as confused as the rest of us when he fell ill with the virus. Using his own experience as a case study (as well as the slightly more high profile case of President Biden), Andy seeks answers from UCSF Department of Medicine Chair Dr. Bob Wachter and UVA Critical Care and Infectious Disease Physician Dr. Taison Bell. They run through the four main treatment methods, which one works the best, and examine the link between Paxlovid and rebound cases.

Keep up with Andy on Twitter @ASlavitt.

Follow Dr. Bob Wachter and Dr. Taison Bell on Twitter @Bob_Wachter and @TaisonBell.

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Check out these resources from today’s episode: 

• Read Andy’s piece in the Atlantic about the three COVID developments he’s holding out hope for: https://www.theatlantic.com/ideas/archive/2022/08/covid-variant-spread-immunity-outcome/671024/
• Check out “The Boys,” a new novel written by Bob’s wife, Katie Hafner: https://www.spiegelandgrau.com/theboys
• Find vaccines, masks, testing, treatments, and other resources in your community: https://www.covid.gov/
• Order Andy’s book, “Preventable: The Inside Story of How Leadership Failures, Politics, and Selfishness Doomed the U.S. Coronavirus Response”: https://us.macmillan.com/books/9781250770165

Stay up to date with us on Twitter, Facebook, and Instagram at @LemonadaMedia.

For additional resources, information, and a transcript of the episode, visit lemonadamedia.com/show/inthebubble.

Transcript

SPEAKERS

Andy Slavitt, Bob Wachter, Taison Bell

Andy Slavitt  00:26

Welcome to IN THE BUBBLE. This is Andy Slavitt. It’s Wednesday, August the 10th. We have a great show for you coming up today answering your question and so many people’s mind. Which is what is it with these COVID bounce backs? And what does it tell us about what to do if we get COVID. This sort of famously relates to one of the many news items last week, which is that Joe Biden got a rebound of COVID. And at first, that rebound was asymptomatic, but then he ended up getting some symptoms. And a lot of people reached out and said, Hey, what’s the deal with this? Should we not be getting Paxlovid. And all that happened to coincide with another very famous important case of COVID that happened, at the same time. I’m talking, of course about my case of COVID. And I happened to actually learn quite a bit as I was going through this case, because I had some recommendations made to me on treatment, which turned out not to be correct. So realize that it is a confusing topic, it’s confusing matter. There are multiple different choices. And not every doctor has the same answer. So we have two unbelievable physicians who are really significantly involved with the clinical practice. What happens when people get COVID and we’re going to walk through and create a checklist of what happens when you get COVID and what the right choices are and how they view the tradeoffs. Bob Wachter, who was kind enough to guest host this show, while I was in the White House is the Chair of Medicine at UCSF in San Francisco. And Dr. Tyson Taison Bell is a critical care and infectious disease physician at the University of Virginia and the ICU. They’re both phenomenal. I think this is a great, great interview. You know, it is interesting in the evolution of talking about COVID that we’re now talking about someone who’s 79 years old, not me, that’s fine. I’m only much, much less than that. And we’re now down to some I think more finer grade questions around is there a bounce back one of the right treatments. It’s just to say we’ve come a long, long way from we were doing shows two years ago, we didn’t even have a vaccine. And a year ago, when we were looking at a lot more deaths than we see today. So, it is a better place to be there are different set of questions, we will explore them all under the bubble. And this is one of them. It’s a banner week in a lot of other ways. We use about monkey pox, new ways that the FDA has kind of come out with or if they haven’t yet, they will come out with based on a call I had with him this week around how to allocate doses of the vaccine more quickly, some research from the CDC which talks about how the large percentage 70% plus of people with monkey pox had several different sex partners over a short period of time. So very tight networks.

Andy Slavitt  04:56

So we’re learning more as we’re trying to get out ahead. And of course, for people who bet attention on Sunday, we had the passage of the inflation Reduction Act, which brings together a whole lot of topics we’ve covered on the show, from the cost of prescription medicine, to climate policy, to inflation, taxes, all those sorts of things. So, we now await a vote from the house, which would be coming up in a couple of days, and then signature from the President. And all of a sudden, we are taking a major leap towards every economy based upon renewables instead of going based on fossil fuels. Very interesting to note, if you’re keeping score that in the last number of months, two months. The gun lobby, the pharmaceutical lobby, and the fossil fuel lobby, all at one point considered infallible, unbeatable. Lobbyists in Washington have seen losses that they had been fighting for literally decades and decades and decades, policies they’ve been fighting for decades and decades and decades come to fruition against them. So guess what folks, elect the right people, the corporate lobbyists who have so much power can be beat back. But this will only work before we get to the interview, if I remind you of one thing, that they are going to be out for blood, these lobbyists, the gun lobby, the pharmaceutical lobby, fossil fuel lobby, they’re going to try to demonstrate that if people who voted against them are going to get voted out of office. So it’s really important for those of us that aren’t spending 10s of millions of dollars lobbying, that we get out and vote for people who have the courage to stand up to those lobbyists. That’s the final point I wanted to make. Now we’re gonna get to Bob Wachter and Tyson Bell. We’re going to talk about the bounce back, what to do about it.

Andy Slavitt  07:08

Welcome doctors, Bob Wachter, good to have you back on the show.

Bob Wachter  07:12

Always a great joy to be here. Andy, good to see you. And I’m glad you’re feeling better.

Andy Slavitt  07:16

And remember, I’m the host of this time, you’re not the host at this moment. And now you’ve hosted the show before Well, Taison if he starts to take over the show, we’re gonna have to put them back in this place.

Andy Slavitt  07:26

Welcome, Taison Bell.

Taison Bell  07:27

Thank you. I’m happy to be on the show.

Andy Slavitt  07:29

Okay, so there have been a famous case of COVID in the news recently, President Biden. And that’s made a lot of questions from listeners on what to talk about. There’s been a more important case of COVID. Of course, in my household, which tell you there’s nothing like as we all know, firsthand experience going, Wait a minute, everything I said, forget all that. Now I’ve got a different opinion. But I do want to actually use this moment as a teachable opportunity for people to get COVID. And I’m wondering if we could start maybe with you, Bob. So when gets a positive test for COVID, let’s say a rapid home antigen test? How do they decide whether or not it’s something they should treat? Versus just right out? What should they be watching for?

Bob Wachter  08:10

Yeah, that’s a good question. And all of the you know, everything in COVID is complicated. The decisions about masking and vaccination is complicated. And this is another set of complicated decisions, Andy, you know, what is clear is that we have a set of medicines that can lower the probability of a bad outcome, and do so quite safely. And that’s wonderful. That’s an important scientific advance. The question about whether you should take any of them really hinges on what is your risk of a bad outcome. And this is a complex kind of epidemiologic issue that we all learn in medical school, which is that even if a drug is effective, if the probability that you’re going to have a bad outcome is very low, it might not be worth taking it because you might have to give it to 500 people or 1000 people to prevent one hospitalization, probably not worth it. So this tends to segment itself based on what is your probability of a bad outcome. And I think everybody knows the things that increase the probability if you’re older if you have other medical illnesses. If you’re unvaccinated or partly vaccinated, which is what I call people who’ve had only two shots, the chances that you’ll get sick enough to need to go in the hospital are high. And therefore the effectiveness of one of the medicines that we’ll talk about is high enough to merit it. I think if you’re a relatively young healthy person who is fully vaccinated, by which I mean vaccines and boosters, the probability that you’re going to skate through is really high. And the need to take a medicine to lower the chance that you’re gonna have a bad outcome is pretty low. So it mostly hinges on how likely is it that you’re going to have a tough case?

Andy Slavitt  09:48

So Taison, let’s say, you decide, you know, you’re feeling kind of crummy, who got COVID You’re not sure whether to go in or not. What are some of the things you should watch for that would indicate, hey, maybe, this is something that should come in for is it your fever, your buttocks level, and you talk about that are some of the other things that that might cause you to say, You know what, maybe I should just go in and just see about getting some sort of treatment?

Taison Bell  10:13

Right. That’s a really good question. And the first thing I tell people is that you know, your own body and you know, when things are off, and when you feel that things are getting to the point where you feel like something is wrong, that’s a sign to go get checked out. To be more specific when it comes to COVID. The respiratory symptoms for sure. So if someone’s having breathing difficulty that’s increasing over time, or maybe their exercise tolerance is getting worse coughs getting worse, those sorts of things. And fever is a part of that, that can be managed sometimes. But I basically tell people, if you feel like you’re not, you’re not able to do what you need to do. That’s a sign that get checked out and go see someone.

Andy Slavitt  10:52

You know, one of the reasons why I ended up going to a clinic to see someone was because I actually wanted to have a not just an antigen test, but I wanted to take a PCR test. So it could be efficiently recorded as part of the numbers. And I use that as a kind of an excuse to then say, okay, I’ll get a blood test, and have them check out all the other things. In this case, took a lung X ray, and it turned out I had pneumonia, and a few other things that I probably wouldn’t have done. But that was I was feeling pretty lousy. But that was one of my motivators. Is that reason enough for people to go? Get it checked out?

Bob Wachter  11:28

I don’t think you needed the PCR. I think, you know, if people have a positive home test and symptoms, they have COVID, it was good of you to go and get the test, in part sounds like you wanted it public reported. But you know, we’re missing hundreds of 1000s of tests a day. Whether you do that or not, I think is I don’t think the average person needs to do that. I’m not sure you needed the chest x-ray, if you did not have symptoms of shortness of breath, and if you’re, I don’t know what your oxygen saturation was, but if it was above 95, I don’t know that you needed to come in and get it. This happens in medicine, sometimes we get a test and then it shows a little bit of fuzziness. And then that sort of starts a freight train of oh, we got a treat that I think if you know for the Average Joe, they probably wouldn’t have had the chest x-ray would have felt fine. And so I think the message for I think Taison is exactly right. You know, if you have significant symptoms, it’s important to go see someone than the main symptom who really should worry about sort of beyond fever and aches and congestion. But if you have any shortness of breath, or if that oxygen saturation number is lower than it should be, and that’s sort of below 95-94, then you definitely need to be checked out and see somebody.

Andy Slavitt  12:38

Yeah, I think I had days 93. But it mostly over 94-95. And was feeling crummy is a combination of a combination of factors wanting to get that PCR test recorded, feeling pretty crummy. And then the next thing which I think we’ll talk about, which is I wasn’t eligible for Paxlovid and I thought the monoclonal I’d heard good things about them. I’m 55. So probably right in the cusp, and thought it would help. So let’s talk about treatments right after the break when we come back. Okay, Bob, so people go through the process, they go to the doctor’s office, or they use a service like Emad, which is kind of a virtual way of taking a test and getting treatment and say, you know, what a treatment is warranted? What are the first line treatments and can you talk about some of the benefits?

Bob Wachter  15:56

Sure. So, there are four treatments for which there is strong evidence that they work. And for each one, the evidence is pretty clear that you need to start them within five days of your symptoms. So if you’re a weakened to symptoms, they these are not going to work and your you shouldn’t take them. There are basically two pills. One is the Pfizer pill, that’s Paxlovid. The other is the Merck pill, which is […]. Then there are two treatments that are given intravenously. One is the monoclonal antibody […] and then a remdesivir, which people are probably familiar with, because we’ve been giving in the hospital for a couple of years, three days of treatment with the IV remdesivir works, a single shot of the monoclonal works. The Pfizer drug works, the Merck drug works in terms of which one you should get the one with the best proven efficacy record, meaning the best lowering of hospitalization and death rates is Paxlovid, which in clinical trials showed a 90% decrease in the rate of hospitalization and death for people that took that medicine.

Andy Slavitt  16:59

The Pfizer drug, and that’s the one that President Biden took.

Bob Wachter  17:04

I think quite appropriately, the tricky part of that medicine is that it’s got a fair number of drug interactions. And President Biden had to stop his cholesterol drug, stop his blood thinner, he actually substituted his blood thinner there was on called Eliquis, for aspirin for five days while he’s on the drug. You can’t take Paxlovid if you have severe kidney disease, severe liver disease. So there are a fair number of people who can’t take it. But if you can, it’s twice a day for five days, and it is the one with the best proven efficacy record compared to the others. And then we can we can talk about the others as we go on. But that would be if you can take Paxlovid that would be the preferred drug based on the clinical trials.

Andy Slavitt  17:44

First line treatment, based on clinical trials, Paxlovid, Tai, do you agree with that? Or do you see it differently?

Taison Bell  17:52

No, that’s spot on.

Andy Slavitt  17:53

Got it. So it sounds like for most of us, we’re going to have an outcome like I did, which is even if you’re feeling crummy, if you get one of these therapies, there’s a really, really high chance of clinical outcome. But because both of you are hospital based, I want to just ask the question, let’s say someone’s going through the treatment, or they’re getting treated, I want to know what the trigger is to actually go to the emergency room and potentially get admitted, which I know for a lot of people is quite a scary thing, particularly as people have memories of people being on ventilators and things like this, which I know scares a lot of people. But I wonder if you can talk about, Taison, in the emergency room? What happens when someone presents in the hospital? What can you do for them that they can’t do at home? How often does it work? And how frequently, do you then need to admit somebody versus be able to apply some sort of treatment and be able to send them home?

Taison Bell  18:52

Again, really good question. And a lot of that does depend on like what Bob was talking about earlier, the combination of your risk factors for having severe disease, and what the doctors and nurses see when you actually present the emergency room. So you’ll commonly have basic laboratories drawn your blood counts, your electrolyte levels, those sorts of things. Lots of times patients will get a chest x-ray at that point once they presented emergency room. So we review that, and then it’s a discussion about how at risk are you right now? And how high risk are you for further disease progression. And that might be a combination of what your symptoms are now what time course you are in the course of your disease and whether you’re requiring oxygen or if you’re on oxygen, whether that level has significantly increased. And so we use that combination of factors to determine if someone needs to be in the hospital or potentially leave from the emergency room. The treatments that are available in emergency room remdesivir sometimes can be given intravenously in the emergency room Paxlovid can be prescribed from there. And then when patients are admitted to the hospital, typically, we are especially if they’re on oxygen, we’re looking at therapies like dexamethasone, which is a steroid medication that suppresses the immune system, because we know that usually by the time someone presents with COVID, severe COVID, in addition to the virus itself, they’re also dealing with the downstream sort of immune complications that can actually cause ongoing damage.

Andy Slavitt  20:21

Cytokine storm kind of a thing?

Taison Bell  20:23

Exactly, yeah. So we’re trying to modulate that in addition to treating the virus, and then a lot of it is supportive care, giving oxygen, trying to minimize the chance that in hospital complications can happen. And in managing appropriately. So if oxygen levels escalate, they may go from Bob service to my service in the ICU, or they might need more specialized devices to deliver oxygen, or potentially go on a ventilator.

Andy Slavitt  20:48

But it sounds like, and Bob, maybe firmness, what I’m hearing is, there’s a lot of things that they could do for you short of admitting you know, perhaps giving you remdesivir, making sure you’re hydrated, helped address your fever that can send you right home, and that it’s not necessarily a trip to the ER isn’t necessarily a trip to a hospital, you know, staying in the hospital overnight. Does that sound fair?

Bob Wachter  21:11

Yeah, I think that’s a fair way of putting it together, these four outpatient treatments are very effective. And it really the only people that need to be in the hospital are folks that need something that you can only get in the hospital or at are at such high risk of a deterioration that they need to be there to be safe. And the most common thing would be their oxygen level has fallen to the point that either they require supplemental oxygen, or that it’s just too risky. They’re kind of on the edge. And if they deteriorate any more, you don’t want them to be home. There are other things that can bring people in the hospital, they’re not able to keep down fluids, and they need intravenous fluids, if they’ve had blood clots that require hospitalization, but by and large, the main thing that’s going to determine do you need to be in the hospital is the oxygen level. And it’s, you know, in the early early days, where we only really had IV remdesivir, people got hospitalized something sometimes for that, once the pills came out, and particularly Paxlovid, we now had treatments that are pretty much as effective. So you don’t really need hospitalization for a medication unless you’re sick enough to need to be in the hospital. Because there’s stuff that we can only do in the hospital.

Andy Slavitt  22:21

So before we get to the main event topic here in a second, we’re gonna talk about his rebounds. And we’re not talking about NBA rebounders, we’re talking about the rebound cases of COVID. For those of you who thought you’re listening to a different show, we’ll talk about my case a little bit. So Bob, I contacted you, a couple days into this, you were kind enough to respond and give me some advice, which I think you’re gonna give your phone number out on the show so that anybody in America can contact either one of you in the show notes in the show notes. Exactly. So I took advantage of having a network of people that I know not everyone has a chance to have access to and some part because I was getting really conflicting advice. As I went into this clinic, they gave me the monoclonal antibody, which for those of you haven’t done this, it took about a minute to go into my hand. And what I can report is, it seems like it was very, very effective. I’m a big fan. And well, I know it’s not the first line treatment, and it’s a little bit more difficult because you gotta go in to get it versus take a pill. It feels like it made me feel a lot better. But the other thing that happened is they prescribed like five other medications for me. They prescribed dexamethasone, in an outpatient setting, they prescribed an antibiotic for some reason, they prescribed the Merck drug, in addition, and a couple of other things, blood thinners and aspirin and Pedialyte and Tylenol that pretty much was nothing in my medicine […] told, didn’t told me to take. And then you know, my own doctor, what I read in the list by them said you should take none of those. So, you think my case is somewhat of an example? Like how much confusion is there out there? Is there a solid evidence base that most doctors follow? Is there a lot of prescribing? Is there a lot of confusion? There’s a lot of under prescribing? What’s the situation out there?

Bob Wachter  24:13

First of all, you know, I think your story is pretty concerning, because most of the things that at least some of the docs you saw were prescribing have no evidence behind them. They’re not quite as out there as ivermectin and things like that where there’s at least some evidence that in some situations, they help but in this one and the one you were in, there’s no evidence that any of them help and at least some possibility that some of them could hurt. I think you know, there’s a lot of confusion out there among physicians, this is a new still new disease, the evidence base changes all the time. And I keep up with it. And I know Taison does, you know, every day reading it, synthesizing we’re both in institutions where we have colleagues that kind of do this for a living, you know, UCSF online has guidelines that we go to, to see what the latest treatments are. And the treatments, it’s every bit as important to know what doesn’t work as what does work. So let me go through what people were telling you. dexamethasone. So as Taison said, incredibly strong evidence, one of the real advances we had in 2020 Was that for someone who’s sick enough to need high levels of oxygen, if you put them on a steroid and the steroid that was used was dexamethasone, you lower the mortality, that is for that particular situation. extrapolating that to using it in a relatively healthy 55 year old guy whose oxygen level is okay, maybe a smidgen down. There’s no evidence to support that, and some evidence that it might even hurt. And people might quite rationally wonder, like, how does that work? You tell me it helps if someone’s very sick? Why wouldn’t it help if you’re not that sick. And the reason is steroids, we use them a lot in a lot of diseases are always a double edged sword. And in this case, they are a particularly double edged sword. And the reason is exactly the one that Taison gave, when someone is sick enough to be in the hospital and falling oxygen and maybe might need to be on a breathing machine. The problem is not just the virus, it’s that the virus has progressed to a point that their immune system is beginning to overreact. And so tamping down the immune system is a good thing to do and has been demonstrated to be an important thing to do for hospitalized patients, for you on your first or second day of symptoms. At that point, you want your immune system to be in DEFCON five, you want your immune system to do everything it can to be attacking the virus. What is steroids, what does dexamethasone do, it damps down your immune system, that’s the last thing in the world you need to have done. And the studies of the use of steroids in outpatients with mild to moderate disease, not only don’t show benefit, they actually give a pretty good signal that you’re harming people. So absolutely the wrong thing to do. And I think a study came out several months ago, showing that about 20% of doctors prescribe it. So that’s just wrong. The others are a little bit more benign, but still not evidence base no evidence that for an outpatient, with mild to moderate disease, giving them a blood thinner, is the right thing to do unless they need a blood thinner for some reason which President Biden was on a blood thinner. And when he had when they needed to stop the blood thinner to give them the Pfizer drug, they put them on aspirin, that’s reasonable. But for you, unless you’ve had blood clots, no reason to do that. Antibiotics, the theory is if you have a viral infection, sometimes you then can set up a secondary bacterial infection. But there’s really no evidence that giving it what we call prophylactically, before you have a bacterial infection is a good thing to do. And some risk of harm because of antibiotic resistance if you’re giving people antibiotics they don’t need. So there’s a lot of stuff you’re prescribed that I think has absolutely no evidence behind it.

Taison Bell  27:55

What’s fascinating about that is it illustrates some of the traps that healthcare providers can fall into, in that we feel like we need to do something or multiple things to try to make either ourselves or the patient feel better. And so in addition to the evidence based things, there’s kind of all these other things that are kind of tossed in there, because we’ve seen that some COVID-19 patients can have blood clots, so why not a blood thinner? We’ve seen that, you know, hospitalized patient need steroids, so why don’t we give it now, but many of the things that we can do are just not the right thing to do. And that’s why it’s important to stick with what’s evidence based and to you know, supportive care out of that the only thing that we didn’t mention Bob was a Pedialyte, which I think water would have been a good substitution, it’s fine. And you need to make sure that you stay hydrated. But we need to be careful to avoid this trap of feeling like we just because we can do something doesn’t mean that we should do that.

Bob Wachter  28:55

I think Andy was crying like a baby. So that’s why they felt like they needed to give that.

Andy Slavitt  28:59

That’s true. I didn’t mention that. I should say this that it won’t surprise either of you to hear this. The physician who prescribed this I want to say incredibly caring, incredibly attentive, and has hundreds and hundreds and hundreds of COVID patients has been seeing COVID patients on the frontline practices mostly geriatric practice and absolutely believes doing the right thing. And I just want to say this, someone who absolutely believed they were doing the best thing for me.

Taison Bell  29:28

Like Bob said, this this is hard. The literature is changing on a daily basis, and we’re trying to keep up with it. And even those of us who are looking at this stuff every day it’s hard to keep up with sometimes so it’s extremely hard for providers out in the community.

Andy Slavitt  29:41

Well let’s go to break and we’re going to come back and talk about rebounds. Whose your favorite rebounder, Tyson?

Taison Bell  31:10

Bill Russell?

Andy Slavitt  31:11

Oh, yeah. The appointed one.

Andy Slavitt  31:16

I’m guessing Bob’s is Draymond because he’s in San Francisco.

Bob Wachter  31:19

No, I’m such a I sort of think about sports in terms of what I used to follow when I was a kid. So it’s Willis Reed.

Andy Slavitt  31:26

Old school. Okay.

Taison Bell  31:28

You got to toss Dennis Rodman into there, though, too.

Andy Slavitt  31:32

Anybody but Bill Laimbeer. Okay, I get a lot of questions. And I’m sure you as well, particularly since President Biden saw his rebound case of COVID. About this idea of a COVID rebound. Taison, you want to start with what’s happening when you see a rebound case?

Taison Bell  31:54

Yeah. So basically, rebound happens when you contract COVID. You have symptoms, or you test positive, and your symptoms improve, maybe you test negative, and then after some small period of time your symptoms get worse, you test positive again, or maybe both actually happen. And what’s confusing about it is because now we have all these therapies and we’re giving people therapies like the Merck drug and Paxil COVID. And what we’re starting to separate out is the fact that rebound is just a phenomenon of COVID. And I’m not sure how strongly link Paxlovid should be linked to rebound in and of itself, because it happens in both folks who have been treated with Paxlovid, and without Paxlovid.

Andy Slavitt  32:40

What often does a rebound happen?

Taison Bell  32:42

So the most recent study was a little over 500 patients who had COVID, they did not receive Paxlovid, 27%, so a little one, and four, has symptomatic rebound after their symptoms have begun to improve, which is that’s fairly common.

Andy Slavitt  32:56

Wow. Is that more with recent variants? Because it seems like some higher than it used to be am I wrong?

Taison Bell  33:02

Yeah, we there’s more we need to understand about the Omicron severance. But what does seem to be the case that this is really knocking people down for the count and people are getting very symptomatic with this. You know, we’re avoiding a lot of hospitalizations with the effects of vaccination and boosting but people are getting sick. Now, in this trial […] those patients are the people in a trial actually had complete resolution of their symptoms. So their symptoms completely went away. And then they came back. And then the last subset that they looked at, and this was actually President Biden’s case where they did not have symptoms, but their viral load rebounded. And they were checking nasal swabs and they tested positive again, but did not necessarily have symptoms that was 12% of the participants. So, it’s becoming more clear that rebound is a phenomenon of COVID itself and Paxlovid whether there’s some blankets there. You know, you still need to understand more about that. But it’s always important to understand the intent of these drugs for Paxlovid is to prevent severe disease coming to the hospital dying of COVID-19, as Bob said earlier, very affected by that 90%. So, Paxlovid is doing his job, the vaccines and boosters are doing their job as well. And this seems to be a phenomenon that we’re dealing with. But we have to be very careful about linking one to the other.

Andy Slavitt  34:23

Bob, I want understand how you see it also may be coming on because of the public linking to Paxlovid. Which curious whether you think there is a link, you know, I know there are trials now to extend Paxlovid from the current five days to seven and 10 days and to see if that reduces the rebound. What are your thoughts?

Bob Wachter  34:45

Well, I lived through this because my wife had it and she had what turns out to be a fairly typical case took Paxlovid felt better the next day. Finally tested negative on day eight, which is the average time for people to test negative and Paxlovid does not seem to hasten that felt just fine days 8 through 12, day 13, developed new symptoms started testing her again positive and was positive with symptoms for another five days and went on to have a form of long COVID. She’s mostly better now, but two or three months out, continue to have a lot of fatigue and a lot and some brain fog and couldn’t help, you know, wonder whether the rebound contributed to that, although there’s no evidence that that is definitely true. So, this is one I find incredibly confusing, because, you know, Tyson’s exactly right. Rebound happens in, in the absence of the medicines. But boy, it feels like it’s happening more in people who have taken Pax COVID. And, you know, when you think about the president, and Peter Hotez and Tony Fauci, and you can sort of name the number of people it reminds me of, you know, the IRS doing these audits on James Comey and Andrew McCabe and saying, oh, that could be random, it just feels not random. It feels like there’s something going on.

Andy Slavitt  36:05

So given your wife’s experience, would you take Paxlovid? Or would you advise her to take Paxlovid if you were in the same situation?

Bob Wachter  36:11

I thought a lot about that. I would, I think I would take it if I got COVID now, I think the evidence that it lowers your mortality and hospitalization risk by 90% has not been disputed. The rebound is unpleasant, but not risky. Almost no one has gone to the hospital with rebound, the main risk is you need to do exactly what the president did, which is go back into isolation because you are infectious. I wonder about whether there’s some relationship too long COVID. That’s but that’s a wonder there’s no evidence of that. And so I’m back to where I was in the beginning, which is, you know, my risk for a bad outcome as a 64 year old guy with four vaccine shots in me is really very, you know, quite low, but not zero. And I think the benefits of Paxlovid outweigh the risks, even with the possibility of rebound. Now, the 5-10 day thing, I actually think is a policy failure on our part. I think the rebound issue was very clear three months ago, when I and others started writing about it, and to read after the President got it, that the Pfizer is in discussions with the FDA about possibly starting a trial to figure out whether 10 days works better than five, that’s something we should have been doing three months ago, it’s the easiest clinical trial in the world to do. We’re getting 40,000 or 50,000 doses a day of Paxlovid just follow a bunch of people with five days, 10 days and follow their symptoms and follow their rapid test and see how they do think we should know that by now. And the fact is we don’t and I think I know the President’s doctors considered giving him a longer course decided not to in retrospect, maybe they should have. But the EUA says five days is the right dose. I’m guessing it’s not I’m guessing that that really 7 or 10 days is the right dose to fully suppress the virus.

Taison Bell  37:56

Yeah, I agree it seems like we’re using a blunt instrument. And when we should be using more finely tuned doses that line up better with what we know about the pattern of viral shed.

Bob Wachter  38:08

One of the interesting things, you know, as people get rebound, you kind of have to figure out what to do. The first thing you need to do is assume you’re infectious again, sadly, you need to go back into isolation. There’s absolutely documented cases of people spreading the virus during rebound. If your rapid test is positive, you’re infectious. That’s the best way of thinking about the rapid test. Second question comes up is should I do anything in terms of treatment? And I think the answer is no. I think that the evidence that rebounds, you know, the vast, vast, vast majority of cases are mild, rare hospitalization risk. But interestingly, Tony Fauci by report took a second course of Paxlovid. That, of course, is off what the EUA says you should do. I’m told that he had pretty significant symptoms, and he’s 80 or 81 years old, so I get it. But the only proven benefit of Paxlovid Is that it lowers your risk of hospitalization. And the risk of hospitalization for rebound is close to zero. So I think the justification to even think about another course of treatment is do you believe that rebound increases the probability of long COVID? If you do, then you could see why people might be inclined to take it. But I think based on what we know today, I would say you ride the rebound out, you go into isolation, you treat the symptoms, I don’t think there’s a justification to taking another course of an antiviral.

Andy Slavitt  39:31

Well, Tony will be in the bubble next week, and maybe we will ask you about that. Let me push the Paxlovid question a little bit around in the following way. There’s, you mentioned drug interaction. So the lot of people like myself, who aren’t eligible for Paxlovid, people complain about a side effect they call the Paxlovid mouth, which is I think some sort of taste thing which is unpleasant, and I don’t know if I can quite describe it because I obviously didn’t t take the drug and don’t have experience with it.

Bob Wachter  40:01

My wife said like chewing on rebar.

Andy Slavitt  40:04

Oh, it sounds great. Were you cooking rebar?

Bob Wachter  40:08

No, no, not, rhubarb, but not rebar.

Andy Slavitt  40:11

Okay. And I will tell you that other than the fact that it’s a pill and you can take it at home. I found the monoclonal antibody and I taught, you know, other people who’ve had experience with monoclonal antibody. Like I was pretty sick. And I got clear, I cleared up very, very quickly. And after I got over a little bit of fatigue, started feeling a lot, lot lot better. So, look, we only have our own experience and clinical trial of one person and one family. Or even you know, three famous people who got a bounce back are a little bit. You know, it’s not how we should be making decisions. But I will say that if someone asked me, hey, I’m not sure about taking Paxlovid, what do you think of the monoclonal antibodies? Based on my experience and things I’ve heard I’m a big fan.

Bob Wachter  40:59

That’s not unreasonable. I think the evidence base behind Paxlovid is a little bit stronger the prove the efficacy number that 90% is a little bit higher than the monoclonal but you could easily make the argument you know, one and done. You know, it’s more expensive. It’s more unwieldy to get people in to get an intravenous dose than to go to Walgreens and get a pill. But I’d say, you know, that’s a little bit of a clinical toss up at this stage. And, you know, I think it is tricky, because we all use our experience as gospel. And of course, it’s possible you would have felt better the next day anyway. But I you know, I think it probably worked in you and it was, if you can take PAC 12 It’s certainly it’s the right call to get I hope it continues to work. We’ve had this you know, experience with each of the monoclonal is that as the new variant come is comes in, and the old monoclonal no longer works, we’re lucky that this one is still working.

Andy Slavitt  41:49

What’s been your experience, Taison, giving the monoclonal, what have you heard from patients?

Taison Bell  41:55

Yeah, we’ve had an infusion clinic here. And it’s worked very well. I feel like we’ve had very good outcomes. I’ve not had a lot of patients who received the monoclonal antibody or Paxlovid for that matter ended up in the hospital and as certainly not an ICU with severe symptoms. So it’s good to have multiple options, because as Bob said, there might be very good reasons to avoid one medicine over the other. And it’s good to have other options that also work.

Andy Slavitt  42:24

All right, we’re gonna close a bit the bubble now with I think, the most useful five minutes in recorded podcast history, which I started to put together a list based upon listening to the two of you, just what do you do, if you get a positive COVID diagnosis. And here’s the list that we’re building, the three of us will call it the bell Walker slash Atlas. Well, we could call it the bell watch, or listen, I’m really not a physician. Okay, number one, quarantine, presumably, you’ve got away, hopefully, in your house where you can keep the rest of the people safe as possible. My wife, Lana, did not get COVID. That happens with a lot of people, I think people suicide magically gonna happen, it didn’t happen. Number two, notify everybody that you’ve been in contact with, over the last, you know, 4-5 days. And in my case, that was probably, I’d say, the most important and stressful part of the whole thing. I know, it feels embarrassing to tell someone that you got COVID. And you may expose them. But nobody gave me permission to take a risk for them. And so when I found out that nobody that I was around, also had a positive case, made me feel a lot, lot better. So that’s the second thing. The third thing, I guess, into determining whether or not to get treatment, is just ask yourself how you feel, and monitor your blood oxygenation level and your temperature, I would add that I think it’s useful to get a positive test. But that’s more for public health purposes necessarily than it is any other reason. And you don’t have to go to a physician to do that you can go to get a PCR test of a lot of different places. And then if you need treatment, because you feel lousy, then I think you’ve got at least as you said for, good options to choose between. And you can use a service like e-med, which if you don’t feel like going to a doctor, or you can go to a doctor go to physician. And then finally you just monitor yourself for the things that would cause you to present to go to the ER while you’re resting, staying hydrated, get better. Is that the right protocol, docs?

Bob Wachter  44:33

I think you need an honorary degree. I’m just you’re getting so close to being physician level knowledge. It’s really impressive. I think that’s a good list. I want to emphasize a couple things, you know, the household attack rate, which is the chances that somebody in your household will get it is 35% maybe a little higher with BA five, but people sometimes assume I’ve been in the same house with this person for a couple days and they’ve had, they’ve been coughing I definitely have it, that’s just wrong. And I had exactly the same experience as you did. And on the other direction. My wife had it, I was with her for a full day, before we knew it, and he did not get it, we went into isolation immediately. That’s really important. I think the notification piece is really important. And just it’s not a moral failure that you got, it happens, this thing is so damn infectious that you should feel like okay, I got it. And but you’re really doing this public service to tell people that you’ve had it. I just emphasize again; I don’t think you need to get the PCR things generous of you to do it for public health reasons. But you don’t need it for personal reasons, symptoms plus a positive rapid test you have it, you even sort of going out to get the PCR, obviously, you’re going out into the world. So I don’t think you’d necessarily need to do that. And the treatment you have, based on your risk factors based on your age, go ahead and look at the guidelines, talk to your doctor if you need and emphasize what Taison said, which is you feel this compulsion to do something. But if you’re young, healthy, and you have three or four vaccine shots, and you probably the best thing for you to do is nothing to treat your symptoms stay in isolation, you really don’t need any additional treatment. It really is the people with risk factors who benefit from these treatments.

Andy Slavitt  46:11

How do you see it, Taison? How does this […] with the advice do you give someone who gets positive diagnosis?

Taison Bell  46:16

That’s a very good listen, I have one thing to contribute. And this is honestly going to expose how picky I can be about things sometimes. Quarantine is what we do with someone has been exposed to the virus, if you are positive for COVID, that will be considered isolation. So if you can track COVID, it’s positive, you go in isolation, you tell the people that you’ve been in close contact with they are the ones who go into quarantine, and then isolation. CDC guidance, you know, I would five days with a test. I think a lot of me in addition to a lot of other folks would have suggested going out a little bit longer or using test based criteria. But important point that not everyone can isolate to the extent that they should. And so if you’re not able to do that, you should wear a mask and ideally in 95 masks to really protect others around you, if you can isolate. And then you know, rest and hydrate, manage your symptoms. And if you have those high, those high risk conditions, that’s when they’ll seek out treatment.

Bob Wachter  47:15

One more complexity, Andy is this issue of okay, you’re now testing negative do you need to continue and you’re therefore leaving isolation? Do you need to continue testing because of this possibility of rebound. And obviously that is what happened with the President. And they found that he had virologic rebound, he now had a positive test. My own feeling is that to continue testing, if you have no symptoms is probably overkill. But I do think that after you have tested negative, your symptoms are better. If your symptoms come back, then you should assume that you have rebound should go ahead and start rapid testing. If you’re positive now you are infectious. And you do go back into isolation.

Andy Slavitt  47:53

There’s an important comment, I think to reflect on as we close the discussion, which is, you know, two years ago, we were talking about all the people that were dying from COVID, we were talking about Phil hospitals, we were talking about incredibly overworked staffs, both you and both of your teams, who’ve just done miraculous work, thankless work, to catch a lot of this. And it doesn’t matter, it is a sign of progress. I think that today, we’re talking about things that are still important, but are less serious, like rebounds. And, you know, monitoring your condition in which treatment gives you slightly fewer side effects or is more tolerable given whatever other drugs you’re on. This is a sign if you’re looking for one, that the disease is moving closer to something where the stakes are lower, for most people were at simulated normalcy. Look, I’m gonna caveat that by saying that, as I wrote the Atlantic piece that came out last week, until older, sicker and more frail people can live normal lives of COVID, then we shouldn’t be declaring ourselves anywhere close to past COVID. But with all the things we’ve talked about today, for the vast majority of people, we are now working at smaller and smaller problems and look, go into work, go to school, not you know, in that having to be isolated, those aren’t small problems that themselves but they’re a whole lot better. Then are we going to live are we going to die are we going to be hospitalized?

Taison Bell  49:35

That’s very true. And it’s so easy to get caught up in the problems of the day that you don’t recognize how much progress that you’ve made, both in the hospital and even outside of it. So I’m not struggling with ventilators or we’re getting patients into the hospital to treat them. I staff we’re still having outages because people are getting COVID But we’re not worried about them coming to the hospital. They’re vaccinated and boosted. We’re talking about how children are going to go back to school and that whether children should go back to school and you know that that conversation is progressing them know, we’re moving towards doing more to things that we were doing before. We’re still at this point where everyone’s sick of this. And, Bob, I’m sure you can agree, this has gone on too long. But it’s still here with us. And we’re at this point where between 400 and 500 deaths per day, which is still too much, that’s about 170,000 people per year. That is way beyond any point where we can declare victory on this. So we still have work to do,

Andy Slavitt  50:37

Bob, as you close, your thought, I’ve actually hoping you could tell us a little bit about your wife’s book as you make your last remarks.

Bob Wachter  50:44

I completely agree. Although the you know, the caveat to all of this is vaccination and boosting. It is that that makes this disease milder than it used to be. And you know, if you’re vaccinating boosted, the chances you’re going to die of COVID have become minuscule, not zero, but miniscule. And that just has to be the baseline message. People have to be vaccinated and up to date with their boosters. And then these treatments can rescue people who had very high risk but gotta start off by making sure that people are as protected as they can be people asking about my wife’s long COVID. It’s been sad to watch but also, luckily, I think she’s had the experience that a fair number of people have, although not all, which is that she’s gotten a little bit better each week and is trending toward getting back to being her old self. She has a tiny bit of brain fog, which makes her only twice as smart as me, but hopefully she’ll get back to normal by the time we’re done. Her symptoms improved last week, when the New York Times reviewed her new novel, which is called The Boys, it’s spectacular. And it was about the best book review I’ve ever seen.

Andy Slavitt  51:57

It was a phenomenal book review. Take a victory brag lap.

Bob Wachter  52:01

It was you know, I edited it about I read it about 20 times and to tell you must never read novels. I’ve telling people I read 20 books last year. It’s wonderful, and she’s incredibly talented. Her name’s Katie Hafner, and I hope people take

Andy Slavitt  52:16

We’ll put a link to it. Thank you guys for being on big help, docs.

Bob Wachter  52:21

Thanks for having us.

Taison Bell  52:22

Thank you. It was a pleasure.

Andy Slavitt  52:36

Friday’s episode, we’re gonna be talking to the pediatricians and other experts on monkey pox. And as we’ve started to see outbreaks, at daycare centers, schools beginning, how should we be thinking about getting our kids vaccinated and protecting our kids from monkey pox. They wrestle around on the floor with each other, they do all kinds of physical contact, much more than many adults as a matter of fact, and so people are worried. And we’re gonna explore that topic. Next week, and coming up, Tony Fauci, Jamie Raskin, Rich Corsi and indoor air quality. We’ve got an episode about learning loss and making up for it. All kinds of great stuff. Look forward to chatting with you Friday. Thanks for tuning in.

Andy Slavitt  53:34

Thanks for listening to IN THE BUBBLE. We’re a production of Lemonada Media. Kathryn Barnes, Jackie Harris and Kyle Shiely produced our show, and they’re great. Our mix is by Noah Smith and James Barber, and they’re great, too. Steve Nelson is the vice president of the weekly content, and he’s okay, too. And of course, the ultimate bosses, Jessica Cordova Kramer and Stephanie Wittels Wachs, they executive produced the show, we love them dearly. Our theme was composed by Dan Molad and Oliver Hill, with additional music by Ivan Kuraev. You can find out more about our show on social media at @LemonadaMedia where you’ll also get the transcript of the show. And you can find me at @ASlavitt on Twitter. If you like what you heard today, why don’t you tell your friends to listen as well, and get them to write a review. Thanks so much, talk to you next time.