Lissa’s Note: I’ve been so grateful to use my power, privilege, and platform to broadcast the most trusted source of up-to-the-moment Covid information I trust. Rick Loftus, MD is one of the doctors in my spiritual community with our shared mentor Rachel Naomi Remen, MD. He’s also the most qualified person I know to give the best Covid data, and so far, almost everything he has dared to predict has been accurate. Here’s his latest- offered with love, from him, through me, to all of you. I feel grateful to have the opportunity to share his wisdom, knowledge, and deep care for a world full of a lot of both unavoidable and also unnecessary suffering right now. Let us do our part to prevent the avoidable suffering as best we can. I’ve been sharing some of Rick’s advice on Facebook and not here, so keep up to date by following me on Facebook, in addition to staying on this list.Lisa Rankin, MD
“Most of you have figured out by now that while we had hoped July would be the beginning of the end for the COVID pandemic, thanks to Delta (and possibly other variants in the future; more below), July was a sweet intermission, but we are now in Pandemic, Act 2.
Delta is about 4 times more contagious than “wild” SARS-CoV-2; it attains viral loads 1000 times higher. If anything, this not only means we need to return to the familiar behaviors- minimizing indoor human contact, physical distancing, masking- but we likely need to *intensify* these protective behaviors to avoid Delta.
As many of you know, some internal memos about Delta leaked from CDC about 2 weeks ago. The leak explained why CDC started suggesting masking even for vaccinated folks in areas with “high” rates of COVID (which is applicable to over 70% of our population right now and will be virtually all of the USA by next week). The memos related to an investigation of the COVID outbreak in Provincetown MA at 4th of July. Almost 1000 people got infected, and the CDC investigation indicated that vaccinated folks were not only getting infected but also passing on COVID to *other* vaccinated folks.
This is a game changer. Why? Because with standard COVID, even if vaccinated folks got COVID (expected; no vaccine is 100% protective), they didn’t seem very contagious. That meant vaccines could stop the spread of COVID, and we could get to a point where if enough people were vaccinated, the amount of virus in the community would drop, and even unvaccinated folks would be unlikely to encounter virus and thus be protected (“herd immunity”). With standard COVID we estimated we’d need 60-70% of humans immune, which is why 70% of adults vaccinated was the Biden administration goal.
With Delta, vaccinated can still spread COVID (half as well as unvaccinated infecte–but that appears to be well enough to get the job done)—so herd immunity is no longer likely possible. Even with a new anti-Delta vaccine, we’d need more like 85% of humans immune. Thanks to the anti-vaxxers, the US will likely never get there. Herd immunity is likely no longer an achievable goal- which means we are all likely to be exposed and possibly infected with Delta, sooner or later.
If getting Delta only meant getting sniffles or spending a few crummy days in bed, that wouldn’t be a big deal. And we know by far most vaccinated persons even with Delta won’t be hospital-level sick.
But what about Long COVID or post-COVID complications? As many of you know, I gave a Grand Rounds at my new hospital in this subject about 6 weeks ago. There was a study of Israeli health care workers published in the New England Journal 2 weeks ago. The study period was when the Alpha variant was circulating in Israel- not Delta. Only 3% of health care workers got infected during the study period (which is great; vaccination can handle Alpha). Of those who had COVID symptomatic infections, however, 20% still had symptoms at 6 weeks- very similar to the Long COVID pattern we saw in unvaccinated folks with standard COVID.
My conclusion is that the best way not to get post-COVID complications, is to not get COVID infection at all. Existing literature also shows that the sicker you are at the beginning of a COVID infection, the more likely you are to get post-COVID complications. In the first few months of the COVID outbreak, it became clear that the higher your exposure, the sicker you got- so using masks, etc., is going to help ensure that if you do get infected, it is a “smaller innoculum” and so a milder infection. If we get specific oral anti-viral pills available, the sooner they are started after infection, the milder the infection, and likely, the lower the risk of complications.
By the way, oral antiviral pills target internal proteins of the virus, not the outside spike protein targeted by the vaccines or the monoclonal antibody treatments. Thus, antiviral drugs should work against variants like Delta just as well as against standard COVID.
Delta is not just more contagious than standard COVID; it is also more aggressive. My colleagues in San Diego were seeing more 30 year olds critically sick with Delta last month, and pediatric hospitalists are seeing more kids critically sick from COVID. Again, the vast majority of infections are still mild in kids, and the vast majority of vaccinated adults who get infected have mild cases, but Delta is better at getting around immunity than are standard or Alpha COVID.
I would therefore not allow my child in environments where masking is optional. Having only some of the people around you masking is like a knight wearing only some of his armor against a fire-breathing dragon- if some of his limbs get fried, all of him is going to fry. We don’t leave drunk driving up to personal choice for the same reason- the drunk driver will not just kill himself, he will kill other innocent people, and that’s not his right.
With standard COVID, if one person in a household gets COVID, other household members would not necessarily get infected. With Delta, if one person in the house gets it, the entire household gets COVID. That’s what we’re seeing. The weak link in your bubble is *your* weak link. Period. One standard COVID case, after 3 waves of transmission, on average can infect 8 people. For Delta, it’s 125 people. That’s the difference.
Won’t vaccinations protect us? Based on the Israel data, Pfizer is only about 54% protective against Delta infections, vs 90-95% against standard COVID. The Israelis, unlike the Americans, insist every exposed person in a case get tested, regardless of vaccination status or symptoms, which is why Israel can show us how much the vaccines are failing at preventing infection. (Like many US doctors, I was very angry about such a stupid decision by the “new” CDC- and they finally changed that stupid policy last week when they realized how much trouble we were in with Delta.) Also, Pfizer announced recently that at 6 months, their vaccine’s protection wanes. (Moderna says at 6 months they are still strong, but I’m confident we’ll see the same pattern with that vaccine soon enough.) This Pfizer data was confirmed in the real world by reports this week from an Israeli hospital, where 90% of their COVID admissions now are fully vaccinated persons. (Remember, in a country with a high vaccination rate, we do expect a high percentage of the hospitalized COVID cases to also be vaccinated. What’s reassuring is that the deaths-to-cases ratio is 60-fold lower with the current Israel surge compared to the surge in January. People are getting infected, but we’re not seeing as many deaths, thanks to vaccination. The vaccines do work in preventing death/critical illness, let’s not forget that.) Israel nonetheless has begun giving 3rd dose boosters to those aged 60+.
I just heard from a friend in Coachella Valley where an indoor concert at which all attendees were vaccinated resulted in 12 COVID cases to date–very reminiscent of the Provincetown outbreak. Vaccination alone is not enough to prevent infection.
Your vaccination is like a hand shield, not a full suit of armor. If your goal is to avoid infection (and I advise for now, it should still be your goal), do not rely on vaccination alone to protect you. Use high quality masks and other sensible measures, per below. (See the end of this letter, “So what’s our endgame?”, for my thoughts on where this is going.)
DO I NEED A BOOSTER?
Yes. The US should have already approved boosters to adults with immune issues (blood cancers, immune disorders, autoimmune disease, HIV). The US should also be considering a 3rd dose for those 60+ like Israel is doing. Ultimately I think all of us will need a 3rd dose booster or a “Vaccine 2.0” designed for the mutants like Delta. (These variant-specific vaccines already exist by the way, because scientists knew the current situation might happen- but politicians need to tell the companies to make and deploy such vaccines, and the politicians are dithering- due to the fact that no one wants to accept reality or go “backwards” even though those are the facts.) (Besides Delta, Epsilon and Lambda can also get around current vaccines. Lambda looks esp dangerous, but it’s still a tiny minority of new US infections, and it’ll have to be significantly more contagious than Delta to replace Delta. We’ll need to watch it closely.)
WHAT ABOUT MASKS?
Use them in all indoor environments, and outdoors if you’re standing around for more than 5 minutes in a shoulder-to-shoulder crowd. Use N95 or KN95 masks; cloth masks are unlikely to be enough protection in a high risk environment. I have obtained and am also using Livinguard cloth masks, which have electrostatic fibers woven into the cloth; can be washed and reused (unlike N95 and KN95 masks); and based on German evaluation, Livinguard masks confer protection equal to a KN95. They make models for kids too.
WHAT ELSE CAN I DO?
Use a twice-daily nasal spray to coat your nose with an antiviral coating. You can buy Viruseptin, a Swedish product, off eBay or Bonanza. It contains carrageenan. Xlear is an American product that also confers protection; it contains grapefruit seed extract (GSE). There are other nasal spray brands similar to Xlear with GSE. Studies show broad antiviral traits of carrageenan and GSE in the test tube, including against SARS-CoV-2. Since the nose is where COVID gets a foothold, usually, I think nasal sprays are important protection. Ultimately I think better COVID vaccines will be given by nasal spray rather than shots.
WHAT ABOUT MY EYES?
If you have to be indoors with other humans for more than 15 min, wear a face shield or goggles. Recent research shows even regular glasses are protective compared to no eye protection at all.
WHAT ABOUT SUPPLEMENTS?
While research-based proof of benefit is mixed for some of these, they have low risk of side effects and are not pricey, so there’s little downside to using, so long as you don’t use them as an excuse to eschew protections like avoiding crowded indoor spaces or using masks. Vitamin D3 2000 units daily ensures you aren’t deficient in this nutrient, which helps ward off respiratory viral infections esp in those deficient in Vit D. Zinc 20-40mg daily is reasonable, but I think promptly sucking on zinc lozenges every 1-2 hours for 2-3 days at the first sign of sniffles or scratchy throat may work better- there’s strong literature on all respiratory viruses for this use of zinc. (After a few months of daily oral zinc, take a break. It’s possible though rare to take too much zinc.) Quercetin 500 mg twice daily may be helpful and I use it. Pepcid antacid 20 mg twice daily has had some evidence of protection against COVID and there’s little downside to using it, so I do. I also take melatonin 5mg daily at bedtime.
If I were to suspect I had contracted COVID, I would up the quercetin to 500mg three times daily; add Vitamin C 2000mg daily (and not take it at same time as zinc, as it may make you vomit; space out by a couple of hours); and add NAC (N-acetylcystine) 1000 mg twice daily.
WHAT ABOUT PRESCRIPTION MEDICINES?
The Federal govt has purchased 1.7 million courses of molnupiravir, a new, specific anti-COVID oral medication made by Merck and discovered at Emory University. The drug must complete trials before Merck can apply for emergency FDA approval, and they’d have to make millions of doses, so I doubt we’ll see it available during surge 4, but maybe by surge 5 this winter (we will need it). Meanwhile, I have ordered favipiravir, which *might* work against COVID if given in high doses very early in infection. I ordered from India, but it likely won’t arrive until early Sept if it gets here at all.
Other existing drugs have been tried against COVID. Despite early interest in hydroxychloroquine, when we finally studied it, we learned it was more likely to cause bad side effects and had no impact on COVID. Ivermectin has somewhat better data but some of the studies were really garbage; it might be worth taking if there were no standard treatments available. Fenofibrate and statin cholesterol drugs are being studied for COVID and we’ll see if they help. If you’re already on a statin or fenofibrate, keep taking it.
The monoclonal antibodies like what Trump got appear not to work against Delta. This is not a surprise. When a person tests positive for COVID we don’t check their strain, so doctors may still order monoclonals if someone looks pretty sick or is at risk of getting pretty sick. Since 93% of US COVID is now Delta, it may not help much. Again, it’s perhaps better than nothing, on the off chance it’s not Delta strain.
Steroids only help if you need oxygen, and harm if you’re doing okay on room air. Get a pulse oximeter for home; if you’re above 93%, you don’t need a medical facility. Antibiotics don’t help unless you *also* have a bacterial infection (in which case, you’ll be in the hospital). If you’re not sick enough to be in hospital, you won’t need either steroids or antibiotics for COVID.
WHAT ABOUT TESTING?
Existing COVID tests can detect Delta. As many of you know, Abbott Labs now sells Binax Now, a 15 min test for COVID, over the counter. I bought some on Amazon; $25 for two tests. It is reasonably sensitive (65-70%) at detecting a *symptomatic* COVID case, but only about 35% able to detect an asymptomatic infection (and likely many vaccinated persons who get infected will have no obvious symptoms).
Delta can look like allergies (runny nose, sneezing, nasal congestion, sore throat) or typical COVID (fever, cough, muscle aches). If you have what could be COVID symptoms, *don’t rely on one home rapid test being negative to rule out COVID*. Given the lower sensitivity of the home tests, I’d want to see the test be negative two days in a row at least before deciding it was something else- and I’d assume it’s COVID meanwhile and stay the hell away from other humans, cats, and dogs. I’d also arrange PCR testing at a clinic while home testing- don’t rely on a home test alone if you have symptoms.
WHAT CAN WE EXPECT OF OUTBREAKS, TRAVEL, SHUT DOWNS?
I doubt we will see lockdowns, mostly out of political considerations- the Biden administration doesn’t want to embrace that our hope to get to herd immunity and finish this pandemic has failed, and that we’re going to see surges in autumn and winter at the least.
Based on what’s happening in the UK, which has 60% of population fully vaccinated and has mostly Delta circulating, this current 4th surge will continue to build through around Sept 7, and then drop through Oct 7 or so. I expect end of Oct to be between surges, kind of like last year. We’ll likely then see a holiday surge, just like last year.
Increasingly the use of lockdowns, etc., will be foisted on local health authorities, because the state and Federal governments will be too cowardly to call for such. You can look at the crises in Missouri, Arkansas and Florida to see what letting local health authorities call the shots will mean.
Even those with forbearance and caution are going to get increasingly tired of maintaining vigilance.
Speaking as someone from a high risk community who survived the last pandemic of a lethal virus: Even responsible people will get tired of eternal vigilance and an emergency that feels like it will never end.
SO, WHAT’S OUR ENDGAME?
Again, speaking as someone who survived the last lethal viral pandemic without getting infected, I advise cautious behaviors to delay infection as long as you can. The COVID cases I treated in July 2020 had a much higher chance of surviving their infection than those I saw in March 2020. Likewise, I waited my entire adult life for an AIDS vaccine that never arrived- but we *did* eventually get PREP, instead, which achieved the same protections.
It is likely that we will figure out why some COVID infections produce organ damage and Long COVID fatigue and brain fog, and have preventive or treatment maneuvers to reduce that risk. My advice above on how to make sure your infection is very mild, if it happens at all, is targeted towards the goal of reducing such complications. At end of year I expect the COVID-specific antiviral pill molnupiravir to be available, and that will help ensure any infection that happens will be able to be treated aggressively and early, which should prevent organ injury.
There is some intriguing research suggesting Long COVID fatigue might result from the activation of Epstein Barr virus (EBV) by the immune effects of acute COVID—so I’d also suggest considering starting high dose acyclovir or Valtrex during acute COVID, and continuing it for at least a couple of weeks after recovery. That’s a pretty technical point for those of you who aren’t medical providers, but talk to your treating doctor if you do get COVID, esp if it’s pretty bad symptoms. There’s no proof it would help, but acyclovir and Valtrex are very safe drugs, and can be given as cheap generics, so I see little downside.
I’d suggest a short-term personal goal of aggressively avoiding COVID until you can get a COVID 3rd dose booster, or Vaccine 2.0, and/or the Merck oral anti-COVID pill as needed, and/or we figure out how to ensure a COVID infection doesn’t damage your brain/heart/other organs. (It’s possible that this last goal might take Vaccine 3.0, which will target virus proteins beyond spike protein.)
This advice may mean canceling non-essential travel this fall and winter until we have better protections, like antiviral oral drugs, easily and widely available.
Based on the experience and inferred history of other beta coronaviruses, almost all humans (95-99% depending on the specific coronavirus species) get these viruses eventually. The unvaccinated patients whose plan is “I’ll just avoid it, I’m careful” are deluding themselves. Unless you live in a spacesuit, forever, you’re going to get COVID eventually. In fact, with other coronaviruses, a substantial minority of adults (~40%) will get *two* infections of the same virus in a calendar year. Since they mostly just cause sniffles, or no symptoms, no one really cares. Original COVID was on its way to becoming a similar chronic head cold virus with death rates similar to flu (which, I’ll remind you all, still kills 200 kids in the US each year) in maybe 10 years, unless we’d gotten to herd immunity. That’s what we call “endemicity”- it’s around; frequent; and annoying, but not very lethal. With Delta, while this fall and winter look uncomfortably like last year to me, with possibly substantial deaths in the unvaccinated, mostly, the silver lining is that the time to endemicity may be as quick now as one more year only. (See Lavigne Et al Science 12 Feb 2021: Vol. 371, Issue 6530, pp. 741-745 DOI: 10.1126/science.abe6522 if you want the math on that). For us older adults, however, we’ll still likely need Vaccine 2.0 or 3.0 to keep COVID firmly in the “not lethal” category.
I strongly suggest the podcasts “The Osterholm Update” and the clinical update episodes with Dr. Daniel Griffin of “This Week in Virology” podcast for those who need smart, humanitarian COVID news.
Love you all. Stay safe.
Rick Loftus, MD”