• Original Articles By Dr. Lavin Featuring Expert Advice & Information about Pediatric Health Issues that you Care the Most About

    COVID Update May 9, 2022: The Small Surge; Paxlovid and Children

    By Dr. Arthur Lavin


    • Virus– a type of germ that consists solely of a bit of genetic material (DNA or RNA) wrapped in a protein coat.  The coat gets the genes into the target cell where the genes force the cell to make zillions of new viruses (genes and protein coat), and on it goes.
    • Variant- also known as a mutation, a variant strain of a virus is the same species of virus but with a change in the genetic code.  The change is minor if it has no impact on contagious the new variant is, or how deadly it is, or if it allows the virus to neutralize our vaccines. Variants that substantially increase harm are now listed by Greek letters, the most troublesome one now is Omicron.
    • Coronavirus– a species name of a number of different viruses.  Called corona because its protein coat is studded with spike shapes that form a crown, halo, or corona of spikes
    • SARS-CoV-2– the specific name of the new coronavirus
    • COVID-19-the name of the illness that the new coronavirus is causing
    • Endemic– an illness always present in a region.  One could say strep throat is endemic in the US
    • Epidemic– a sudden burst of an illness that comes and goes over a limited time
    • Pandemic– an epidemic that bursts across the world not just one region
    • Spreadability– how contagious is the disease, how many people will end up infected
    • Symptoms- the experience of being ill, for example- fever, cough, headaches, loss of smell etc.
    • Asymptomatic– literally means “without symptoms”.  For COVID-19 it refers a person infected with the virus but has no and will have not symptoms
    • Presymptomatic– This is a person who was infected with SARS-CoV-2, and will feel sick, but hasn’t yet
    • Severity– what harm does the disease cause, in terms of  how sick you get and how many it will kill
    • Mask- a mask is a loose-fitting cloth or textile that covers the mouth and nose loosely.  A surgical mask is a mask used in surgery
    • Respirator-  for the purposes of the COVID-19 pandemic and other respiratory illnesses, a respirator is a mask that fits very snugly or tightly to the user’s face.  An N95 mask is a respirator.
    • PCR Test–  swabs the nose to detect the genes of the COVID virus.  The genes if detected are almost certainly there, but they can persist long after contagion ends.  Very few false positives, positives can be trusted.
    • Antigen Test (the home kit)- swabs the nose to detect the proteins on the coating of the COVID virus, the spike proteins.  If it does not detect those proteins, you are almost certainly not infected, negatives can be trusted.  These proteins are also on the coating of many common cold viruses, so one positive test may indicate you have a cold rather than COVID.  Two positive home tests though reliably indicate you have COVID.
    • Vaccine Terms
    • Vaccine or Immunization– a dose of a substance that activates your immune system, as if you have the actual infection you are hoping to prevent, leaving you in fact protected from having that infection.
    • Efficacy– the percentage of people immunized with a particular vaccine who will not get infected if exposed to the target infection.  For example, a COVID-19 vaccine will be said to be 95% effective if 95% of people immunized with that particular COVID-19 vaccine will not get COVID-19 if exposed to COVID-19
    • mRNA– DNA works by dictating exactly which proteins your cell will make.  The message on how to construct each protein is delivered to the cell machinery that makes proteins by a piece of genetic material called messenger RNA, or mRNA
    • mRNA vaccine– an mRNA vaccine places a small bit of mRNA code that makes your cells make a protein that is the protein from a virus that alerts your immune system and activates it to make protections against you being infected
    • Viral vector vaccine– a viral vector vaccine takes a harmless virus that is known to infect people reliably and places that weakened virus in a person where that virus will in fact infect the person.  The virus is not only weakened, but also attached to a set of genes  that makes your cells make a protein that is the protein from a virus that alerts your immune system and activates it to make protections against you being infected.

    The Small Surge 

    Over the last few weeks, the Omicron variant of the SARS-CoV-2 virus continues to be essentially the sole cause of COVID around the world.  But in those last few weeks, a very curious type of change has been percolating across the world of Omicron.  And those changes have led to what is being termed a small surge.  The number of cases is definitely going up, but nothing like the terrible surges of the last two winter holidays.

    This small surge is a sharp reminder that humanity has not fully vanquished the SARS-CoV-2 virus, it continues to adapt to our measures, to find ways to continue to spread, and to continue to kill.  As long as it evolves, it will decide what happens next, to a degree no one can predict.

    But, whatever the virus does to evolve, it can be vanquished by humanity if we ever decide to truly unite, achieve universal vaccination of all humanity 6 months and older, and practice good testing and isolation measures.  Since the day in which all of humanity will unite to achieve these steps seems distant, we remain at the mercy of the evolving virus.

    For right now, the dominant variants still are blocked from killing immunized people, but are wildly contagious.

    More than any other variant, the Omicron variant has spawned a series of sub-variants different enough to launch their own, smaller outbreaks, but similar enough to all remain called Omicron.

    With regard to Omicron, it might be helpful to remember that the SARS-CoV-2 virus changes nearly every time it infects a cell, or a person’s billions of cells.  But those copies are typically similar enough to the original that a new variant is not created, or the changes are so large the virus cannot compete with the original virus in that infection and is never heard from again.  Only on rare occasions can a copy of a virus outperform a virus that spreads as prodigiously well as Omicron.  But since that is still possible, the future of this virus remains essentially unpredictable.

    The Current State of the Pandemic here in Cuyahoga County

    As with much of the world, the actual numbers of cases of COVID are up here at home.  If you recall the metric of how many new cases happen each day per 100,000 population, we had dipped to around 1 or 2.  Once that number drops well below 10, we find the COVID tests done in our office all come back negative, schools stop reporting outbreaks, and families stop reporting new cases in their family and friend circles.  That was how it was in much of March and April of this year.

    But now that number has clearly climbed, up to 16.  At this level, we are all once again hearing of schools and day care centers reporting new cases, families are experiencing new cases, our tests are turning positive again.  But at the number 16 new cases per day per 100,000, the vast majority of colds we see remain not COVID.  There are no massive outbreaks reported in local schools, only sporadic reports.  Sadly we are seeing many of the cases in those unable to get immunized, our children under 5 years old.

    At the number 16, Cuyahoga County still remains a county with low level of spread per the CDC.

    My sense of the current level of spread is that it is real, but quite milder than the just past winter holiday season when that number soared to over 200.   Given the active spread, I am in favor of mask use indoors and taking precautions.   But the #1 precaution that will make the biggest difference is to make sure, today, that everyone in your family, and everyone you care about who is 5 years old or older is fully immunized.   The unimmunized, particularly older adults or all with medical risk, are in danger.

    Paxlovid and Children

    Not long ago, a true breakthrough in ending the ability of COVID to kill was the development of two new drugs that used in combination work incredibly well to keep people with COVID from dying.

    The combination is called Paxlovid.   So to start, there is no single drug called Paxlovid.  But if you take two separate medications, one called ritonavir and the other called nirmatrelvir, together, that combination is called Paxlovid.  Any medication whose name ends in –vir is designed to protect against viral infections.  The most famous of this class of drugs, known as antivirals, is a drug that treats infections with herpes viruses, acyclovir.

    Of course, treating COVID gets more urgent the more likely the infection can cause serious and even fatal disease.  And as we all know and remain so grateful for, the younger you are the less likely it will cause any sort of serious disease.   SO it also is the case that as you get older, the risk of severe disease gets quite larger.  And, it works so well that if you have COVID as an adult, and you take Paxlovid, you drop your chances of needing a hospital or dying by a staggering 89%!  Paxlovid had more modest impact on those with mild illness who never would progress to severe or potentially fatal disease.  And it has limited use for those already severely ill, those admitted to a hospital.

    As a result, Paxlovid is aimed at use in those who are just recently infected (has to be within the first 5 days of having the first symptom), but are at increased risk of developing severe illness.

    For older adults, as the risk increases, the benefits of taking Paxlovid are more obvious, and in fact, being much older can qualify as a risk.  That line could be set at 50 or 65 or 70 years old.  Other factors that increase risk, and therefore push one to take Paxlovid, are underlying medical conditions such as being a smoker, high blood pressure, etc.

    The FDA has authorized use for those at risk by medical condition to as low as 12 years old, but for most children ages 12-21 years of age are not at risk medically for their COVID being severe.  And for those 12-21 year olds who do have complex medical concerns, many are taking medications, and many of these medications interact poorly with Paxlovid.

    Further, the ability of infusions of monoclonal antibodies for treatment of mild to moderate COVID prior to it getting severe is as good as that of Paxlovid in adolescents.

    As a result, some medical centers have advised that adolescents would be better off with getting treated for their COVID, if they are risk from severe disease, with monoclonal antibody infusions and not Paxlovid.

    Bottom Lines:

    1. COVID is not done with us yet.
    2. We are currently in what is a mild level of surge, enough to be careful, to use masks and take precautions, not enough to mandate distancing and masks.
    3. As long as humanity is not universally immunized and the virus spreads, new versions can emerge, and the risk of another major round remains.
    4. Paxlovid is a regimen of 3 pills taken twice a day for 5 days now can drop the risk of COVID killing someone by close to 90%, an astounding breakthrough.
    5. Paxlovid is now available to anyone 12 years and old and up with very recent COVID infection (it offers little help a few days after symptoms begin), who are at risk of poor outcomes.
    6. Since adolescents are typically at such low risk of poor outcome, many medical centers are recommending not to use Paxlovid in adolescents, and even for those at risk, to use monoclonal antibody infusions which work as well.   And is safer given that adolescents at risk are often on medications that interact poorly with Paxlovid.
    7. For older adults Paxlovid is a great option, especially those not on meds that could interact.

    My One Takeaway Sentence:
    As long as COVID spreads, the need to have everyone immunized remains URGENT.

    To your health,
    Dr. Arthur Lavin


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