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Local Doctors are Now the Frontline for COVID-19 Response. It’s Not Clear They’re All Ready.

8 minute read
Rivkees, M.D. is Professor of Practice at the Brown School of Public Health. He is a pediatrician and the former State Surgeon General and Secretary of Health of Florida.

The COVID-19 pandemic continues to evolve as the virus mutates to more contagious forms. Despite the new wave and continuing federal effort to address COVID-19, the pandemic response is shifting to local levels. We also need to recognize that health care providers are and will be playing an increasingly important role in COVID-19 control and treatment, similar to how they manage illnesses like influenza.

Tools to fight COVID-19 are freely available to health-care providers, including tests, vaccines, monoclonal antibodies, and antiviral medications. The CDC, White House, FDA, state and local departments of health, media, and many medical organizations have provided much education to practitioners through webinars and print material about COVID-19 prevention and treatment. Yet, despite ample tools and guidance to fight COVID-19, many health care providers are not prescribing effective antiviral COVID-19 therapeutics. Many health care providers are not offering protective monoclonal antibodies to immunocompromised patients. Many health care providers are not registered as COVID-19 vaccine providers. It is recognized that the medical community has endured much during this pandemic. It is also recognized that they can continue to step-up.

COVID-19 remains a serious and highly contagious illness. Since this pandemic began, we have seen waves of new COVID-19 infections globally and in the U.S. We are now seeing new waves of infections caused by new Ba4 and Ba5 Omicron variants that evolved from the recent B2 variants. These newer variants are even more contagious than those before. 100,000 confirmed new cases of COVID-19 per day, about 4000 individuals newly hospitalized each day, and about 300 new COVID-19 deaths.

Because of widespread use of at-home testing, it is likely that there several-fold more new cases of COVID-19 per day than are reported. These case numbers dwarf those seen during flu epidemics and would be much higher if not for public health measures and COVID-19 vaccine uptake by the public. The collective input of the medical community in the face of difficult times is needed to address and prevent this magnitude of illness.

Vaccines. Even with different variants, a COVID-19 vaccine is the best way to prevent severe illness. Prior COVID-19 infection may not protect you against the current variants, whereas vaccines more effectively reduce the risk of severe disease caused by them.

Nearly 600,000,000 doses of COVID-19 vaccine have been given in the U.S. More than 250 million individuals in our country (67%) have received at least two doses of COVID-19 vaccine, and more than 150 million people have received boosters. These vaccines have an excellent safety profile, with benefits outweighing any rare serious risks at all ages.

In the U.S., all those who are six-months old and older can now get vaccinated against COVID-19. COVID-19 is much more serious in older individuals than in children. But more than 1,200 children less than 18 years of age have died, including 300 individuals less than 5 years, have died from COVID-19. About 4060% of severe COVID-19 cases occur in children without underlying medical conditions. Because not all children and adults live in areas where there are health-care providers or have health-care access, local departments of health play an essential role in vaccination efforts, as well.

Abundant evidence shows that having a COVID-19 vaccine booster increases protection against severe COVID-19. Two months ago, the CDC recommended booster shots for those individuals 50 years of age and older and those with underlying medical conditions. Even though there are maybe new COVID-19 vaccines in the fall that are specifically designed to protect against Omicron and its variants, it is still recommended that if one has not received a booster shot, that you receive one.

For those individuals not vaccinated, which includes the millions of children less than five years, speak to your pediatric provider about COVID-19 vaccines. COVID-19 vaccines are recommended by the American Academy of Pediatrics for all age groups.

To facilitate vaccination, physicians and other members of the health-care community should offer COVID-19 vaccines and become COVID-19 vaccine providers. If not, they can contact their local departments of health to enroll.

Evusheld. If you are immunocompromised, which can occur if you are treated for inflammatory conditions, cancer, or have underlying medical conditions, your risk for severe COVID-19 increases dramatically. There are about 7,000,000 people in the U.S. who are immunocompromised. It is recommended these individuals be vaccinated and have COVID-19 booster shots. Yet, some individuals will not have complete protection against COVID-19 even after vaccination.

Fortunately, there is a medication called Evusheld, which contains antibodies that reduce one’s risk of getting severe COVID-19 by about 80%. Evusheld is FDA/EUA approved for individuals 12 years of age and older. This medication is given by injection and can provide protection for up to six months. Evusheld continues to remain effective against the current new Omicron variants.

In 2021 the federal government bought 1,700,000 doses of Evusheld that have been distributed across the country. Despite the considerable number of individuals who are candidates for this medication, much of these doses have been unused. The reason behind the failure of health care providers to prescribe this medicine is not completely known, as there has been considerable federal, state, and medical society outreach to make providers aware, and the medication is available.

Bebtelovimab. Bebtelovimab is a monoclonal antibody that is FDA/EUA approved for the treatment of COVID-19 in individuals 12 years and older with COVID-19, who are at substantial risk for severe COVID-19. During this pandemic, different monoclonal antibodies have been used. Bebtelovimab is now the only one that is effective against the current Omicron variants. This medication is given by intravenous infusion or by an intramuscular injection.

The U.S. government purchased 600,000 doses of this medication. Because additional funding for the federal COVID-19 response has not been approved by Congress, it is not clear that the U.S. will be purchasing additional monoclonal antibodies. But they should be available commercially. Because of the high cost of monoclonal antibodies and the fact that cannot be taken orally, experts view them as a second choice to oral antiviral agents for someone with COVID-19.

Antiviral pills against COVID-19: Paxlovid and Molnupiravir. Antiviral drugs slow the virus from replicating and are for individuals recently diagnosed with COVID-19 and reduce the severity of illness. The medications Paxlovid and Molnupiravir are pills, and Remdesivir is given via IV. Paxlovid is a combination of two antiviral medications. Molnupiravir Is a single drug approved for adults.

The anti-COVID drug Paxlovid should be prescribed within five days of symptom onset to those 12 years or age and older who have tested positive for COVID-19 and are at high risk for progression to severe COVID-19, which includes those who is over age 65 or has an underlying medical condition.

Both drugs have proven effectiveness against COVID-19, but Paxlovid is more effective. There are some medications that need to be stopped when Paxlovid it is taken, and the dose needs to be adjusted if somebody has kidney problems. These medications include anti-cholesterol statin medications that can be safely stopped during Paxlovid therapy and for two days after. These concerns about drug-drug interactions are less with Molnupiravir.

The federal government purchased 10,000,000 treatment courses of Paxlovid and 3,000,000 courses of Molnupiravir. These medications are available in more than 40,000 pharmacies across the U.S. and can be prescribed by your health-care provider at no cost to you. Very recently the FDA authorized pharmacists to prescribe Paxlovid.

Although there has been an increase in the use of these medications over the past few months, they still are under-prescribed. Of the millions of doses that have been purchased, less than half have been prescribed. Despite much available information about these drugs, it was recently suggested that the medical community requires more clarity and information about this medication, which will hopefully be forthcoming from the federal government.

There is talk of a condition called “Paxlovid-rebound,” with which COVID-19 symptoms reappear within a week after finishing a course of Paxlovid. Because of this reported phenomenon, physicians may shy away from this drug when they may benefit from it. Recent studies, however, show that this is uncommon, and should it occur, it does not usually require additional treatment.

In parts of the U.S., these medications are prescribed at test-to-treat sites or by telemedicine when an individual has a positive at-home test result for COVID-19. If you test positive at home for COVID-19, contact your primary care provider, who may call in a prescription at no cost to you. Your local health department may also have links to telemedicine or test-to-treat programs for evaluation.

We are 2.5 years into the COVID-19 pandemic that continues to evolve. Just as the virus is changing, the public health and health-care response is evolving too. COVID-19 prevention and treatment tools are in the hands of health care providers. If you do not have a health-care provider, contact your local department of health or your local federally qualified health center to get care. Health care provider engagement is a necessary and essential part of the pandemic response today, and let’s hope that this engagement will continue to expand.

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