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PAXLOVID UPDATE: EFFECTIVENESS, REBOUNDING, DRUG INTERACTIONS
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One of our biggest public health challenges is to decrease the rate of severe COVID-19 disease in the face of pandemic fatigue, dried up funding, misinformation, and a changing virus. Paxlovid—an antiviral medication—is a tool we still have left.
However, recent data shows concerning trends of Paxlovid use. For example, less than 30% of 80-85 year-olds with COVID are getting a prescription for Paxlovid. This is a major problem. This group is at the highest risk for severe disease and death, even if vaccinated. Improving knowledge, confidence, and thus prescriptions and use should be a priority.
Here is the latest data on effectiveness, rebounding, and drug interactions with Paxlovid. (To see how Paxlovid works, go here.)
Effectiveness
As with vaccines, we rely on two types of data: clinical trials data and “real world” data. Both have limitations, so looking at them together gives us the best picture.
Clinical trials
- The original Pfizer clinical trial tested the efficacy of Paxlovid on “high-risk” individuals: unvaccinated with at least one high risk characteristic, such age 65+ or a comorbidity. This trial was during the Delta wave. Paxlovid reduced hospitalization and death by 88%.
- Pfizer had a second clinical trial testing the efficacy on “standard risk” individuals, for example younger people. The drug was not effective. Pfizer stopped the clinical trial early.
Real world data
- A study published in Israel found Paxlovid reduced hospitalization by 70% and death by 80% but only for people aged 65+. There was no benefit for 40-64 year olds.
- The vast majority of people in this study had some level of immunity (vaccination or prior infection). This means that Paxlovid helps vaccinated older adults.
- A study in Hong Kong found Paxlovid was useful among people >60 years old and <60 years old with a comorbidity. This study also included people who were vaccinated.
- Another study in Hong Kong found that, among hospitalized patients, Paxlovid reduced viral load and helped patients recover faster.
- A non-peer-reviewed report on 560,000 U.S. patients found similar patterns:
- Among those 65+ years, 73% had a lower chance of hospitalization and 79% a lower chance of death.
- When separated by vaccination status, the benefit remained. This analysis did not account for other variables that could explain this relationship, but the authors said this analysis is currently underway and, thus far, results have not changed.Unadjusted age distribution of COVID-19 hospitalization and death rates by Paxlovid use from March 1, 2022, through August 1, 2022, for patients with a complete primary series of COVID-19 vaccination but no documented booster vaccination.
Rebounding
COVID-19 rebound occurs when a person takes the drug for a few days, tests negative, and then tests positive again several days later. Since my last update, we still don’t know the “true” frequency in which this happens after Paxlovid. But we have discovered other important pieces to the rebounding puzzle:
- Rebound doesn’t impact immunity. A small but important study found that rebounding after Paxlovid does not interfere with the immune system’s ability to develop protection. In other words, if you take Paxlovid, you will still make antibodies and T cells. In fact, this study found that you make more antibodies.
- Rebounding is common without Paxlovid. A preprint found 1 out of 8 people rebounded without Paxlovid. Those that rebounded were more likely to be older. Among those that rebounded, only 10% had symptoms.
- Rebounding may happen more frequently with Paxlovid. Another preprint found rebounding after Paxlovid (3 out of 11) was more common than rebounding without the drug (1 out of 25). Why this is the case is one of our biggest unanswered questions.
- Rebounding is mild. Another important question is whether rebounding leads to severe disease or milder disease. In other words, does it cause harm? Small studies report the majority of people experience milder symptoms during rebound compared to the initial infection. LA County reports no severe COVID-19 cases after rebounding, too.
Interactions with medications
One limitation to Paxlovid is that it can interact with other medications. The older the person, the more comorbidities, and the more medications. This may explain suboptimal uptake. The good news is there aren’t too many drug-to-drug interactions. The Infectious Disease Society of America released a report summarizing the the top 200 prescribed drugs and their interactions with Paxlovid. They found only 2 drugs have interactions so severe that Paxlovid should be avoided:
- Rivaroxaban (Xarelto)
- Salmeterol (Serevent)
With the help of a clinician, other medications can be managed so Paxlovid remains an option. Be sure to get advice from a clinician.
Other benefits?
Severe disease is not COVID-19’s only outcome, so a comprehensive assessment of Paxlovid is beneficial, especially if we are considering populations outside of 65+:
- Transmission: A randomized control trial of more than 3000 people found that Paxlovid does not prevent COVID-19 infection.
- Long COVID: Unfortunately we do not know whether Paxlovid reduces the risk of long COVID.
Bottom line
Vaccination is the safest and most effective way to stay out of the hospital.
Paxlovid acts as a fantastic second line of defense among unvaccinated people and vaccinated older adults. This is the case even if they rebound.
We are entering winter with limited tools, so Paxlovid needs to be top of mind.
We’re simply missing too many opportunities to use it among high risk people.
WESTCHESTER 1ST WEEK OCTOBER CONTINUES COVID INFECTION PACE.
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8,800 COVID HOSPITALIZATIONS IN NEW YORK CITY IN THREE MONTHS.
CDC: MONKEY POX DECLINING NEXT FEW MONTHS DEPENDING ON BEHAVIOR.
3,984 MONKEY POX CASES IN NEW YORK STATE LEAD NATION.
WPCNR COVID SURVEILLANCE. Statistics from New York State Covid-19 Tracker. Observation and Analysis by John F. Bailey. October 8, 2022:
Westchester County 2022 Covid-19 infections spread at double the rate they spread one year ago, averaging 180 new cases a day through Thursday compared to 98 a day the first week in October in 2021.
County Executive George Latimer and Dr. Sherlita Amler held a news conference at the County Board of Health Tuesday starting a drive to encourage vaccinations for covid and the flu. Mr. Latimer received his fourth Covid shot, and a flu shot at the same time. and Dr. Amler emphasized Westchester residents should return to get all their first vaccination series if they have not already done so. Dr. Amler said it has been the county experience that in the fall infections of covid rise due to increased social gatherings.
WPCNR notes that the Labor Day Weekend and unknown covid infections in the first week of school rose September cases 2022 to 5,205, 133 less than the September 2021 cases of 5,338.
However Westchester this September and first week in October are spreading at an 8% of those lab-verified tested being positive compared to 2% infection rate last September when the fall. Remember that was a time when we had no vaccine, but had strict social distancing and gathering rules and masking was in effect. This is why folks should listen to Mr. Latimer and Dr. Amler and just get it.
She implored Westchester residents who are fully vaccinated to go on the www.westchestergov.com website and click to the Department of Health and make an appointment to get the variant at the Board of Health.
(You can see that 2 minute segment on the White Plains Week report it’s right at the top of the program on www.wpcommunitymedia.org)
In Westchester County, here is what covid did this week: 1,085 new infections with Friday results due this afternoon and Saturday tomorrow.
Around Westchester, here are the areas that are responsible for the most infections (over 100):
Yonkers, Mr. Vernon, New Rochelle, White Plains, Yorktown, Greenburgh, Cortlandt, New Castle and North Castle, Mt.Pleasant-Pleasantville, and Tarrytown-Sleepy Hollow. As of October 6, those 13 towns and cities, accounted for 67% (2,075) of the 3,089 Westchester infections the last two weeks, and those 13 towns averaged an aggregate of 1,200 new daily infections daily.
What is more disappointing is in 5 weeks, those towns have not improved their covid fighting.
How is the Mid Hudson Region doing?
Orange and Westchester and Rockland and Dutchess Counties are infecting steadily. Overall in a week the Mid-Hudson region tested 5,684 and 445 were confirmed positive, an infection rate of 7%. Westchester was 5.6% with an average daily infection rate in 7days of 20.3 persons per 100,000 of population, that is 211 a week which times 4 weeks is 844 people which is a little shy of the 1,336 we actually recorded last week.
But here’s the twist: These are lab-test verified positives. With more infections than there should be then persons may not be quarantining after testing positive, let alone or worse, not confirming they are positive with a lab test, then getting sick spreading the disease and then the lab records the tests when persons catch the covid from non quarantiners, or socially mingling positives, that might explain why the infections are higher than the 20.3 spread rate.
This home testing started April 4 2022 is not working in giving us a true picture of the disease spread pattern.
In my opinion, it is spreading disease since April 4 creating this new wave in the making as Karelyn Jettelina, the epidemiologist writes in her Your Local Epidemiologist newsletter October 5, which you can read on this website.
On the Monkey pox disease, the Center for Disease Control says the disease is declining, and should continue to do so. There are 26,577 cases of Monkeypox in the U.S.
New York state has 3,984,second to California at 5,135. New Jersey has 723 and Connecticut, 131.
Florida has 2,572. Texas, 2,410. Georgia, 1,839.
WHITE PLAINS WEEK — THE SEPT 7 REPORT–SEE IT ANYTIME ON www.wpcommunitymedia.org
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THIS WEEK EVERY WEEK ON
WHITE PLAINS WEEK
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Woman Long Time Domestic Abuse Victim, Serving 12 Years for Killing Boyfriend, Has Sentenced Reduced.
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WPCNR LAW JOURNAL. From the Westchester County District Attorney. October 8, 2022:
The Westchester County District Attorney’s Office has, for the first time, consented to the resentencing of a domestic violence survivor under New York State’s 2019 Domestic Violence Survivors Justice Act (DVSJA).
The DVSJA gives the court discretion to resentence defendants who suffered sexual, psychological or physical abuse that significantly contributed to their criminal conduct.
Westchester County District Attorney Miriam E. Rocah recommended a five-year resentence, the maximum under the DVSJA, for Jonitha Alston, who has been serving a 12-year sentence for her manslaughter conviction for the 2016 stabbing death of her boyfriend, Dennis Graham.
Judge Robert Neary vacated the original sentence, of which Alston served nearly five years, and granted our recommendation of a five-year resentence, with five years of post-release supervision, in Westchester County Court on October 7, 2022.
“I want to thank the court for its thoughtful consideration. After a careful review of the motion filed by Ms. Alston under the Domestic Violence Survivors Justice Act, and a recent examination by an expert psychologist, we concluded that Ms. Alston was subject to physical and psychological abuse at the time of her offense, and the history of this abuse, combined with the perceived threat to her daughter at the time of the offense, significantly contributed to her commission of the crime,” DA Rocah said.
“The Domestic Violence Survivors Justice Act is an important evolution in the way the criminal justice system views survivors of abuse. The legislation is narrowly crafted and requires a strict set of eligibility requirements, which we took into consideration during our careful and thorough evaluation of this request.”
“This is a life-changing result for Ms. Alston and her family, friends and community. This case shows what can be accomplished when the DVSJA is coupled with a prosecutor’s office that views domestic violence survivors through a compassionate, holistic and trauma-informed lens,” said Ross Kramer, Director of the Incarcerated Gender Violence Survivors Initiative at Sanctuary for Families, one of New York’s largest service providers and advocates for survivors of gender-based violence that played a lead role in the passage of the DVSJA.
“Pace Women’s Justice Center is so pleased to see the Westchester County DA’s Office use the Domestic Violence Survivors Justice Act for the first time to reduce the sentence of an incarcerated survivor of domestic violence. It is fitting that this type of action was taken during Domestic Violence Awareness Month, giving voice to survivors. It speaks loudly of the Office’s understanding of the complexity of domestic violence prosecutions within the criminal justice system,” said Cindy Kanusher, Executive Director for Pace Womens Justice Center, which provides free legal services to victims and survivors of domestic violence, sexual assault, and elder abuse.
TONIGHT at 8 A SPECIAL REBROADCAST OF “PEOPLE TO BE HEARD” JOHN BAILEY INTERVIEWS COUNTY LEGISLATOR BEN BOYKIN ON WHAT’S HAPPENING ON COUNTY LEGISLATIVE DISTRICT REDISTRICTING. FIOS CH. 45, OPTIMUM CH 76 & WWW.WPCOMMUNITY MEDIA.ORG
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PROPERTY TAX EXEMPTIONS PASSED BY BOARD OF LEGISLATORS FOR SENIORS AND PERSONS WITH DISABILITIES
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WPCNR COUNTY CLARION-LEDGER. From the Westchester County Board of Legislators. October 5, 2022:
The Westchester County Board of Legislators unanimously voted to enact the Senior Citizens and Persons with Disabilities Home Owner’s Tax Exemption at their meeting held Monday night. The new law expands income eligibility for property tax exemptions by increasing the maximum household annual limit from $29,000 to $50,000.
The amendment to the current local law is a direct result of the suite of tax relief bills signed by Governor Kathy Hochul on August 8, 2022, allowing local municipalities the option to raise eligibility requirements (S.3085A/A.3956A). Eligibility for this exemption is limited to Westchester County homeowners that are either a person with disabilities or a senior citizen aged 65 years or older. The goal of the law is to allow more residents the ability to age in place within their current communities, especially for those on fixed incomes, by maintaining affordability during a time of record-high inflation.
Legislator Vedat Gashi, Chair of the Budget & Appropriations Committee and a lead sponsor of the bill, said, “We wasted no time in opting-in to the new tax exemption guidelines because it is our duty to help as many people as we can. Through this expansion, previously excluded individuals will for the first time qualify for this tax relief benefit and not have to worry about being priced out of their beloved neighborhoods.”
Legislator David Tubiolo said, “Our seniors have worked their entire lives without asking for much. All they ever wanted was the opportunity to provide for their families and contribute to their communities. We need to do our part to take care of our seniors in return and ensure they receive all the support they need to make Westchester their home forever.”
COVID STATE OF AFFAIRS: OCT 5 FROM YOUR LOCAL EPIDEMIOLOGIST — NEW WAVE COMING– FALL BOOSTER ESSENTIAL
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Here we go again. The start of a new wave. Eyes are on Western Europe, as hospitalizations are uniformly increasing. As we’ve seen throughout the pandemic, some are hospitalized “with COVID19,” but it’s important to note that the Germany’s numbers are reported purely as “for COVID19.” In other words, not only are infections increasing, but so is severe disease.
Interestingly, no new subvariant is driving this wave, as the majority of cases are still the “old” BA.5 subvariant. This means changing weather, waning immunity, and/or changing behaviors are the culprit. This theory is only solidified when we see patterns are not changing in neighboring country Israel, for example, whose weather hasn’t started changing yet
This is concerning because subvariants are brewing. They only make up a small percentage of cases for now, but they are gaining ground; historically, we feel their impact when they make up ~30-50% of cases. These subvariants will eventually add fuel to the fire.
Currently, we have a “subvariant soup” on the horizon—a mix of many different Omicrons trying to dominate the space. Below is a figure of the Omicron subvariants we are closely tracking. Each subvariant has ~10% growth advantage over BA.5, meaning it has the ability to create a wave, but not a tsunami. (As a comparison, Alpha had a growth advantage of 7%/day; the first Omicron BA.1 had a growth advantage of 25%/day).
Convergent evolution in Omicron subvariants. X-axis represents the number of spike mutations. Figure by Mark Johnson
It’s a very busy figure, but there are three specific things to notice:
- Convergent evolution. Subvariants with similar mutations are popping up independently across the globe. CA.1 popped up in one place with a R346X mutation, while BQ.1.1 popped up in a different spot with the same mutation. This pattern has been the hallmark of COVID-19, so this isn’t necessarily surprising. What is noteworthy is where these mutations are happening—a spot that helps Omicron continue to partially escape immunity.
- Notice BQ.1.1 (in red above). This is a direct descendant of BA.5. While it has the most spike mutations, we picked the BA.5 formula for U.S. fall boosters. Our boosters will work best if this subvariant dominates in the future. For now, BQ.1.1 is winning the race in Europe, so this may have a good chance of taking over in the U.S. We may get lucky.
- This is what we know. More than 90% of testing and sequencing has been stopped across the globe. This means we are largely flying blind and there may be a surprise in the mix we are unaware of just yet.
United States
Given the U.S. has mirrored European trends throughout the pandemic, a wave in the U.S. is likely coming.
Source: Pandem-ic
On a national level, SARS-CoV-2 wastewater has been decreasing the past two weeks, but that deceleration has started to level off. If we zoom in to specific jurisdictions, like Boston, there are concerning signals with sudden increases in viral wastewater levels. Wastewater will continue to be a huge asset moving forward as an early indicator of transmission in communities.
Wastewater COVID-19 Tracking | Massachusetts Water Resources Authority
We really don’t know what reported case and testing numbers mean these days, but for what it’s worth national test positivity rate has also plateaued. In the first two years of the pandemic, this metric was a consistent early indicator of what was to come.
(CDC)
If we combine five of the top new subvariant leaders in the U.S. (referred to as “Pentagon”), it’s clear that case acceleration is brewing below the surface. Given the current growth, we will likely see an impact on national metrics in mid-November.
The height of a U.S. wave is partially dependent on the number of people who get a fall booster.
Unfortunately, it looks like the majority of Americans will be going into the winter ill-prepared.
A new Kaiser Family Foundation survey found 40% of Americans are unsure if the booster is recommended for them, including about half of fully vaccinated rural residents (54%), Hispanic adults (51%), and those without a college degree (49%).
There is clearly a failure of communication and outreach. This must be a priority as vaccines continue to protect against death, severe disease, transmission, cases, and long COVID-19.
So far only 7.6 million Americans have received their fall booster.
Hospitalizations per 100K, by vaccination status in New York City. Top blue line is unvaccinated. Bottom lines are 1 booster and 2 boosters. Source Here
Bottom line
We may be in for a bumpy ride this winter.
SARS-CoV-2 is already gaining ground thanks to weather and behavior change. We expect growth to accelerate with subvariants on the horizon. There’s a lot you can do, but the lowest hanging fruit is to get your fall booster.
Also, if you’re older and test positive, remember Paxlovid.
WESTCHESTER RESIDENTIAL SALES SUSTAIN PRICES IN 2022, DECLINE IN SALES. INTEREST RATES HURT ABILITIES TO BUY. LOW INVENTORY KEEPS PRICES UP. INFLATION INFLICTED ECONOMY INHIBITS CONFIDENCE.
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WPCNR REALTY REALITY. From Hudson Gateway Realtors (Edited) October 4, 2022:
Westchester County, third quarter single-family home sales of 2,006 declined 15.6% compared to the third quarter of 2021.
However, when compared to the third quarter of 2019, single-family home sales in Westchester were up 3.4%.
Condo sales in Westchester for the third quarter of 2022 decreased by 24.5% and co-op sales were on par with the previous 3rd quarter.
The County single-family median sale price of $872,000 posted a 2% increase over 2020.
The County condo median sale price of $460,000 was slightly down, and the co-op median sale price of $204,500 was 2.3% higher than the previous year 2021.
The real estate market in the lower Hudson River Valley and greater New York City suburban area continued to be battered by chronic low inventory, rising interest rates and persistent inflation during the 3rd quarter of 2022.
Resiliency and consistent buyer demand are still evident, when compared to the pre-pandemic market of 2019 three years ago.
(Editor’s note: In 2019, readers should remember real estate was lamenting the lag in sales in 2019, and prices were down. Realtors were calling homeowners in 2028 and 19 asking them to put their homes on the market. Homeowners declined because so much value in their homes had been lost due to falling prices of real estate due to reduced demand. Covid came on the scene in 2020 and people were eager to leave New York City and wanted to move into Westchester where covid was not such a danger, igniting the greatest real estate boom Westchester has seen since the 1950s.)
While total transactions are down from the previous year, median sales prices continue to increase throughout the market, driven in large part by low inventory.
HGAR contemplates a traditional seasonal market is returning replacing the reality frenzy the last two years.
Around the Mid-Hudson region, sales were not robust.
In Putnam County single-family home sales of 326 were down 10.7% compared to the third quarter of 2021, but when compared to 2019, the number of sales were almost identical. The median sales price of $505,000 was 8.6% higher than the third quarter of 2021.
Rockland County experienced a drop in transactions, with single-family home sales
down 9.2% and condo sales down 15.8%. Continuing the comparison to the second quarter of 2019, the 2022 quarter numbers are slightly ahead. The single-family median sales price of $660,000 for the third quarter of 2022 in Rockland County was 14.2% higher than 2021.
In Orange County the 3rd quarter single-family home sales number of 1,019 was down 14% over the 2021 second quarter, and the condo sales number of 138 was off an even steeper 23.3%. The single-family home median sales price was up 9.1% at $420,000 and the median condo sales price of $270,950 for the third quarter was a 13.4% increase over the 2021
third quarter.
In Sullivan County the single-family sales number of 300 transactions was just slightly higher than the 298 total of the previous year and the median sales price was up more than 10% percent when compared to the 3rd quarter of 2021
Shifting closer to the city, the Bronx market continued to show signs of strength, in the 3rd quarter of 2022, with singlefamily home sales ahead 9.2% over the 3rd quarter of 2021. The median sales price of $630,000 was 6.8% ahead of last year. However, condo sales lagged from the previous 3rd quarter.
As we have stated in previous sales reports for 2022, there will continue to be challenges in comparing sales numbers to the pandemic year of 2020, when the market came to a grinding halt in the second quarter, and the post-pandemic market of 2021, when pent up demand drastically sped up typical buying cycles.
Given negative economic headlines and the ongoing debate of will there or won’t there be a recession,
it’s obvious that the market will not be immune to such significant headwinds. However, the 3rd quarter sales numbers do not necessarily support the doom and gloom forecasts that many prognosticators like to make, especially when making comparisons to the pre-pandemic market of 2019.
Also, the strong labor market seems to be playing a role in counterbalancing some of the adverse economic factors. As was the case at the end of the second quarter, the wild card in this analysis is a potential recession in 2023, and the length and depth of one should it occur. Until then, the numbers
support a conclusion of a resilient real estate market that ishampered by low inventory but still supported by strong buyer demanc.