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Scott Webb: Though many of us are enjoying things like eating out and traveling, COVID-19 is still the elephant in the room, so to speak. And I'm pleased to be joined today by Dr. Barry Kitch. He's the Chief Medical Officer at Emerson Health, and he is going to give us an update on COVID, tell us about the effectiveness of paxlovid in treating COVID patients and try and explain monkeypox to us.

This is the Health Works Here Podcast from Emerson Health. I'm Scott Webb. Doctor, it's so great to have your time today. We're going to talk about the pandemic, where we are today, we may even get to monkeypox later on in the podcast. But as we get rolling here, where are we? You know, with this phase of the pandemic, when we think about our regular life or whatever was normal before, what's your sense of things? Where are we?

Dr. Barry Kitch: It's terrific to be with you. And I'd say that we're at a more regular point in our lives than we've been since the onset of the pandemic. So the good news is that people are going out to restaurants, they're going to concerts, they're traveling, flying, all in volumes that just wasn't true before. And we're able to do that because of the great progress that's been made in treatment and in the vaccinations, that are available to people. So people are vaccinated and we know that prevents severe disease in most instances, and we now have antiviral treatments that are effective in preventing or markedly decreasing the chance that people who get infected become sick enough that they require hospitalizations. So I'd say great progress allows that sort of normality that I just described.

Having said that, it's obvious that we are still not back to our normal lives. If you go to any healthcare facility, you'll be asked to wear a mask. If are around people that aren't part of your household, and you have immunosuppression of some form or other risk factors for severe disease, you may be wary, and not unreasonably, because of the potential that you might become infected. So, much better, but not fully there yet.

Scott Webb: Not all the way there yet, but it's so funny, doctor, because, you know, things that we took for granted three years ago, just as you say, going out to a restaurant and eating in public, we're starting to do that again. And it does feel regular. It feels normal. And another normal thing for many of us, especially before the pandemic, is, you know, going to other people's houses or vacationing at a friend's house. And wondering if you suggest that we sort of voluntarily self-test before we go? If so, how often? What are your thoughts on that?

Dr. Barry Kitch: So self-testing is something that is worth diving into just to better understand what we mean when we talk about self-testing and both how it can be useful and then it's limitations, and we can talk about how you might then use it when you're thinking about, "Do I self-test before going to spend time with friends or on a vacation with somebody that's not part of my household?"

So self-tests are typically the rapid antigen tests. And the rapid antigen tests are terrific because you can perform them yourself in your home. They're relatively low cost at this point in time and the supply is good. So there's this accessibility and ease. And if you have a positive self-test in the right circumstance, then you can take that as pretty definitive evidence that you indeed are infected. So they're good for all the reasons that I described. And when they're positive, they're a good evidence that you're, in fact, infected.

The problem with the self-test -- and I'll bring it back to this question that you asked about, does it make sense to self-test before you get together with people -- is that their sensitivity, meaning how likely you're going to have a positive test if you actually have COVID is not great. So there are many people, and we've all heard stories who will test even when they have symptoms and be negative or negative for days before they finally become positive by the self-test. So there are many times when people who use the self test will test negative, but in fact they have disease.

So I'd say that with that in mind, the best way to get the most value from a self-test is to use it when you suspect that you have COVID because, if it's positive, then you're done. You've gotten your answer. If the test is negative, either in that setting, when you have symptoms or other reasons to think that you might have developed COVID, if it's negative, then you're not going to want to conclude that it's been definitive, so you may still have COVID, and either additional testing with the rapid antigen test or PCR can help to resolve that.

If you're asymptomatic, don't think you've been exposed and are simply wondering, "Do I have COVID because I'd feel better if I knew that I didn't in getting together with a family?" I'd say, we need to be aware that it doesn't always pick it up. So I would be wary about thinking of it as definitive information. I'd say there's probably not a downside to doing it, because if it's negative, okay. And if it's positive, you found something. But it shouldn't be seen as a definitive test to do. And so I'm reluctant to say that people use it knowing that having tested negative by self-test, they're good to go.

Scott Webb: I want to talk to you about flying on planes. My daughter plays travel basketball, and we're flying to a bunch of tournaments and we've already done so this summer. And she and I wore our masks and many people didn't. And I'm not judging anybody who does or doesn't. Wondering from an expert though, what are your thoughts about traveling on planes for vacations or basketball tournaments and whether or not we should still be wearing our masks?

Dr. Barry Kitch: Well, the first thing I'd say is it's wonderful that you and your daughter are back to traveling for basketball tournaments. That is part of the more regular life. It's wonderful to see that happening, something that is happening across all sorts of arenas of activity. And it really does reflect that we've come so far. So I'd say that being on an airplane without a mask is one of those things that puts you at some risk and it's for a couple reasons. First, there are no requirements that people test before they get onto an airplane. I'd say that, we all know situations where people are feeling a need to take travel for whatever reason to get to where they need to go. And it might result in people pushing it a little bit. Even if they think that they may have some symptoms, they may get on that plane. So if you're going to be on a plane with somebody who hasn't tested necessarily, you'll be close to a number of people, there may be many other people who aren't wearing masks. And so wearing a mask on an airplane makes a lot of sense to me. I'd recommend if you're going to do it, that you use a high quality mask. And by that, I mean, an N95 or a KN95, both of which are pretty accessible at this point in time, and it gives you some protection. You're going to have the best protection, if both you and the persons next to you are wearing a mask. And that may not be the case, but it'll give you some protection in a setting that, in contrast to a grocery store encounter or going into a business, probably puts you at increased risk if the person around you were infected, because of that prolonged contact that's close.

Scott Webb: Yeah, that sounds right. You know, we were talking earlier about the regular life stuff. So, as I said earlier, before the pandemic, we would go and we would visit and we would vacation and things like that. And people are now hosting parties again, right? People like to feel normal and socialize and all of that. So again, back to that self-test thing, do you believe that if we're going to host a party, that we should ask people to self-test? I mean, certainly, I guess we have the right to do that and they have the right not to, or not to come. But in general, would it be a good practice, a good thing to have people test before they come?

Dr. Barry Kitch: I'd say given the limitations of self-test, which is that often, they're negative even when people have infection. So again, imagine that the people who are doing the self-testing are largely people who don't think they have COVID, they don't have any symptoms. We know enough to know that often enough, even if they actually have COVID, the test is going to be negative. So, remember that self-testing doesn't provide any sort of certainty that the people who are doing that self-testing and showing up for a party don't have COVID. So that's something to bear in mind.

A second thing is, are there other things that you can do? And we'll again come back to the idea of self-testing, but there are other things that you can do. So for example, if you have a party and July 4th certainly is going to lend itself to doing it outside because often the weather is terrific and it's easy, especially if you've got larger numbers of people to be outside. And I'd say that that's a great strategy to decrease the risk that you or others are going to infect one another or become infected. So an outside party where people can have some distance and certainly where the air circulation that we see outside is something that will accomplish the thing that you're trying to accomplish, which is to decrease the risk. And I think in that setting, requiring that people self-test, probably not necessary.

If you're going to do something indoors, I'd say again, that self-testing tests are accessible. They're not all that expensive. There is some modest amount of reduction in risk that could come from people testing negative. So not an unreasonable thing to do. But just be aware, particularly if the people who are going to be at that party include those that are immunocompromised and may not have had a good response to the vaccine or at risk for severe disease. Be aware that the self test doesn't provide certainty about whether or not somebody's infected.

Scott Webb: I think I know the answer to this next question. What if I've had COVID recently? Is it okay for me to travel? Well, if you just got over COVID yesterday, no, you can't travel today. But is there a time period? You know, what's the distance between having had COVID and when it would be safe to travel or appropriate to travel?

Dr. Barry Kitch: The CDCs recommendations are fairly clear around what people ought to be doing to help both recover and then to keep people safe. So the first is that they recommend that people isolate for the first five days after the development of COVID and that would mean that you're, of course, not traveling. And then, for a full 10 days, so the next five days after that first five days, that people wear a mask if they're out and around others. And wearing a mask if you're out afford some protection. But if you're wearing a mask and another person isn't wearing a mask, there's certainly some risk there. So what I would say is that the first 10 days after becoming infected are days during which it probably makes sense for people to stick close to home, certainly not engage and travel where they're going to be putting others at risk that might not, for example, be wearing a mask when they're around them. So that would be ideal. So if people were going to maximize diminishing the risk to others, then there would be caution in those first 10 days.

The other thing to know is that at some point, after recovery from infections, and now let's talk about after those first 10 days, you probably do have pretty good protection against becoming reinfected. And so, a question that others might have is, "After I'm recovered, am I now good to go? Can I now have that regular life and not have to worry?" And I'd say that there's probably a window in there where the risk of becoming infected again is very low. But that window fades fairly quickly. And particularly now with the continued evolution of the virus and variants coming along, it can literally be weeks between when somebody's infected with one variant and another variant takes hold that they're not protected against. So people will need to be wary of how long that window is that they've got that natural immunity.

Scott Webb: You've mentioned about it's a relatively small window if we've had COVID where we have pretty good protection, I wanted to ask you about rebound COVID. You know, is that a thing? And if so, what does that mean exactly?

Dr. Barry Kitch: Rebound describes somebody who has developed symptoms from COVID, tested positive for COVID, then has improvement. And typically, we'd say rebound means that the symptoms have gone away and/or they've tested negative. And then, two or three, or up to a week later, they have a recurrence of those symptoms and/or a recurrence of testing positive. So that's what we mean by rebound. You get better and then you get worse again. Typically when rebound happens, the second bout of symptoms is a milder bout, although not necessarily. It would be unusual for somebody who doesn't get sick enough to require hospitalization to then have rebound and get sick enough. So I think it's typically milder. And if it's not milder, it's typically not severe enough for somebody to require hospitalization. So that's what rebound is.

The other thing to say about rebound is that it's been much in the news because it's being observed to happen in a number of people who've received one of the most effective antiviral treatments, which is paxlovid. And paxlovid is a terrific drug. When I mentioned earlier, that life is more regular than it's been at any point since the onset of the pandemic. Certainly one of the things that's helped to make it more regular is the treatments that we have and paxlovid is chief among them. It's a pill. You take it for five days. It's now widely available and it's been shown to be very effective in reducing the risk of hospitalizations or development of severe disease.

But we've also seen that some proportion of people, and it's probably a modest proportion, maybe in the order of five to 10%, although some people suggest it might be a higher proportion of people, will develop rebound symptoms and even positivity by tests after stopping the paxlovid. So they take it for five days. Symptoms will get better often pretty quickly. Tests will turn negative often pretty quickly and quicker than if they'd not been taking paxlovid. They'll stop it. And then they'll have a recurrence of symptoms. And again, this is not the majority of people who take paxlovid, but it's a meaningful proportion of people. So it's something to be aware of. It's certainly not a reason to not take paxlovid if you're at high risk for development of severe disease. So those who are 65 and older, have cancer or immunosuppressed and there are other risk factors for severe disease, then paxlovid makes a lot of sense, but it's something to be aware of.

Scott Webb: Yeah. Well, I think that's why you have chief in your title because you absolutely read my mind. I was going to go to paxlovid next. I wanted to ask you about long-haulers, long COVID or COVID long-haulers, whatever we're calling them, their symptoms from COVID are prolonged for months, possibly, and perhaps even beyond. So where are we at with the long-haulers?

Dr. Barry Kitch: Long-haul COVID is something that obviously is being studied intensely now because we know it's a real phenomena for a significant number of people and very impactful. And I would say that there is still a lot to be learned about risk factors. Who is it that develops long-haul COVID what is the natural history of it? So for some people, long-haul COVID is going to be different than what's true for other people. So what's the natural history and how does that break out in terms of the proportion of people who have the different courses that you might see with it, and then what are the effective treatments for it?

So, I would say that, there was a lot of work being done to bring answers to those questions. It's something that is part of the impact of COVID. So in acute care settings, a big part of what we've all feared, is the severe illness that requires somebody to be hospitalized. It's the deaths that can occur in individuals because of COVID. But long-haul COVID is obviously impactful well beyond what you might see in the acute phase and important to understand and then address impact on the lives of many across the country.

Scott Webb: And doctor, you know, if you believe social media, or media in general, monkeypox is the next COVID, right? That's what I see when I open up Facebook, maybe that says something about the people I'm friends with. But at any rate, I wanted from an expert to know what are your thoughts on monkeypox? Is it the next COVID?

Dr. Barry Kitch: I think the good news about monkeypox is that it's probably not the next COVID. So I think we can feel reassured there. But it's an illness that really has caught the attention to the public because it's present in ways that it hasn't been. We've seen outbreaks of monkeypox even in the US in the past, although it's generally been known as a disease that's endemic to parts of Africa. But now, we're seeing it around the world. And we've seen more than 300 cases be diagnosed in the United States, just in recent weeks. And there is every reason to believe that the actual case number is considerably higher than that.

Having said that, the good news about monkeypox is that it is something that requires close contact in order for it to be spread in ways that just isn't true for COVID. So it's skin to skin contact, typically with lesions or with bodily fluids that gives rise to the spread of monkeypox. It doesn't appear to be spread in the same way through aerosolized respiratory secretions that COVID is spread. So we think that the risk from casual contact is very, very different. So I think that's the reassuring thing about monkeypox is that it's something that requires that close skin to skin contact. It can be transmitted via fomite, so things like respiratory secretions or bodily fluids that might be in bed sheeting, for example, could be means of transmitting it. So people who know that they've got a family member that's got monkeypox would need to be aware of those things. But the risk of acquisition of monkeypox is quite different.

The other thing that's different about monkeypox is that there haven't been any reported deaths in all the cases that have been reported in the US. And that's consistent with what's known about it, which is that it tends not to cause severe disease. So COVID was of great concern early on, not just because of the ease with which it was spread as a virus that infected the upper respiratory tract and the lower respiratory tract, but also because of the severe illness that it produced and the deaths. And we just haven't seen that with monkeypox.

Scott Webb: Doctor, one of the real pleasures of my job is I get to speak with experts, doctors, nurses, scientists and so on. And every once in a while, I get the head honcho, the big cheese on, you know, the chief medical officer. And I really do appreciate your time and your expertise. We kind of started this conversation talking about regular life, normal life, and are we back yet? I just want to give you an opportunity here at the end to reassure folks that great progress has been made, continues to be made and that maybe you believe getting back completely to our regular lives, whatever they were before COVID, may be possible, maybe in our future at some point.

Dr. Barry Kitch: Scott, I would agree with you that the great news about where we are is that we are in a much, much different spot than we were a couple of years ago. We have vaccines that we know are protecting people from severe illness and death. We have antiviral treatments that can help to do the same. And we know much more about how to reduce the risk of transmission. So all of those things have given us the ability to go back to doing many things that so many of us enjoyed prior to the pandemic and are once again now able to enjoy.

I would say that over the coming months, what we can expect is even more progress that's going to help us to get to even more normality and provide some more certainty about the future. The current challenge to us with regards to the virus is that we're in the midst of this rapid evolution of yet another variant of the Omicron variant that is proving better and better at evading the antibodies that are produced and the immunity that gets produced from vaccine or from prior infection. And we are rapidly moving towards vaccines that are going to have some component of the Omicron virus in them, so that we get immunity specifically to the Omicron portions of the virus that the current variants have been using to evade our vaccination. So I think we're going to continue to make progress in that regard. And I expect we're going to continue to make progress with the antiviral treatments. We'll know better, I suspect, how to prevent the rebound that we talked about from paxlovid or prevent it from occurring. So what I predict is that, over the course of the coming months and the next year, we'll get better and better around vaccination, around treatment. And that'll allow us to continue on a trajectory of further return to normalcy.

I will say that we shouldn't be discouraged and believe that we're not making the progress that I'm describing if episodically we're asked to don the mask again, because there's been a surge. And as we evolve, our ability to combat the virus, the virus of course, is going to continue to try to push back. And there may be times when it's going to make sense to wear a mask, when you're out and about in ways that you might not have a few weeks or a month prior. And I think if people can roll with that on the occasions that it's asked of them, along with the other advances that I'm sure that we're going to make scientifically, I think we're going to continue to get to a better place.

Scott Webb: That's perfect, doctor. It's always reassuring to talk to experts, and hear the optimism in their voices. And I can hear it in yours. As you say, there may be times where we have to put the masks back on or, like me this summer, flying on planes. But in general, progress is being made, there's reason for optimism. And it was just really great speaking with you. So thanks so much. You stay well.

Dr. Barry Kitch: Wonderful to speak with you. Take care.

Scott Webb: And visit emersonhealth.org for more health information.

And thanks for listening to Emerson's Health Works Here podcast. I'm Scott Webb. And make sure to catch the next episode by subscribing to the Health Works Here, podcast on Apple, Google, Spotify, or wherever podcasts can be heard.