Clarifying COVID Confusion

Stop wearing your masks! Oh but wear them during these circumstances. You don’t need a booster at your age! Why are so few people getting their boosters? You can end your isolation after five days! Except for all of these people who should really isolate for 10 days.

I’ve been giving COVID-19 health advice for over two years; first as a nurse, then as a journalist, and most recently as Saint John’s Health Center’s COVID Vaccine Educator. During this time, the only thing I’ve been able to consistently rely upon is how maddeningly inconsistent and confusing the health guidance has been. There was even one point during the pandemic where I contacted the LA Department of Public Health to make them aware that their guidance was directly contradicting that of the CDC, which they begrudgingly admitted after a dozen emails showing them their own education, and then corrected. And let’s not forget this story I published, basically an exposé of the blatant inconsistency and confusion of the use of gloves during the pandemic. Neither administration has handled this smoothly, and at this point the majority of Republicans and Democrats consider this pandemic a thing of the past. And that has left a sizable portion of the populace scared and shuttering themselves in their homes — likely far more than is prudent.

Boaz Hepner’s vaccine lecture to the hospital and community from 12/23/21

I continue to welcome emails and phone calls from anyone who is trying to understand things better. In the past week alone I have had several friends both vaccinated and unvaccinated asking me how to best navigate their new COVID diagnoses, so this motivated me to do two things:

1. Type up something here, knowing that brevity is my kryptonite.
2. Record a new video full of hot tips and suggestions, which can be seen here.

The new video of tips and suggestions

So without further ado, the frequently asked questions I’m being asked recently:

Everyone keeps testing negative before finally testing positive. Why are the tests so inaccurate?

Actually, the tests are far more reliable than you think. The issue is that people are often not taking the right test and at the right time to get a reliable result. Think of a PCR (molecular) test as being something to examine what happened days ago. Like a CSI team analysis. It does not look for real-time contagious virus, it looks for something that was in you recently. As such, a PCR test is a wonderful tool to use four days after your exposure.  Three days might work but could be too soon; so if you had an unmasked night where a few friends caught COVID, I recommend waiting four days to take a PCR, and can rely on those results quite well.

If on the other hand you wake up one morning with symptoms, most people immediately test themselves with a home rapid (antigen) test, but this is also too soon. An antigen test actually tries to detect real-time virus. If that test is positive, it shows you actively have it in you, and are likely contagious. The flaw in most testing is that it is done too soon to detect the virus. The virus replicates/multiplies daily, and there has to be a high amount to be detected by tests. So my advice is to wait at least 24 hours before using a rapid test, and ideally 48 hours to rely on the results.

Are there many false-positive results?

It certainly does happen, but with the FDA-approved tests you can assume a positive is accurate, and errors are more like one in a few hundred. This is true for both PCR and antigen tests.

It costs me too much money to keep testing!

Ready for something you likely don’t realize?  Almost every insurance plan covers eight free home tests per person, per month. That means that if you have a family of four, you are entitled to a whopping 32 FDA-approved rapid home tests each month, and can do it again the next month! Some pharmacies will have you buy the tests and then get reimbursed through your insurance, and others including CVS will do it for you. Just ask your pharmacist to look up your plan and many times they can just hand you a bag to take home. You can also use their app or follow this link to do it yourself. Sometimes, as with my family’s plan, it just requires a doctor’s prescription for the tests. So please stock your medicine cabinets with these tests so you have them for when you need them.

And while there are some private companies charging for testing, most are still free, whether PCR or antigen.

Should I get tested again after a positive result?

As soon as you test positive, there’s no reason to get another PCR test. It can remain positive for weeks beyond when you actually have the virus (because it is a forensic exam, as explained earlier). But this is when having a good supply of home antigen tests is ideal. You may continue to be contagious until day 13, or you may be contagious until day six, it just depends on your case. Many people do not even hit their peak viral load until day five or six, so the idea of isolation recommendations ending at day five is quite laughable to many epidemiologists. Here is my recommended timing to re-test (antigen testing):

1a. If you have no symptoms at any point after five days (including if you never had symptoms in the first place), take a test. If it is negative, take a second one to double check. If both rapid antigen tests are negative, you can safely end all precautions.

1b. If either of the tests come back positive with a solid line, try again two days later.

1c. If the only line that comes back is faint, try again the next day. Faint line implies there isn’t much left. Hooray! (Fair warning: I’ve seen the faint line linger for three days or so.)

2a. If your symptoms continue through day 10, take a test at that point anyway, as your symptoms may remain even after you are no longer contagious. If the test is negative, you can safely end your precautions.

2b. If your test comes back with a faint line, check again the next day. If your test comes back with a solid positive line, you may as well wait two days to test again.

It is important to realize that regardless of what day you are at, a positive line in an antigen test means you continue to have active virus within you.

How do I know what day to start the count?

This common question even confused me for the longest time, but is quite simple if explained properly:

1. If you have symptoms and test positive, you consider the day your symptoms began as day zero.

2a. If you have no symptoms and test positive, the day the positive test was collected is day zero.

2b. If you then develop symptoms, you change day zero to the day the symptoms begin.

By the time my symptoms start, haven’t I already spread it to my friends and family?
When COVID began there was a high amount of pre-symptomatic spread, because by the time you felt yourself getting sick, you’d already been contagious for a day or more. Here comes one of my favorite side-benefits of getting vaccinated, something that is rarely discussed. By having good antibody and memory cell protection in advance, your body should start fighting the virus sooner. Most of the time the first symptoms you will feel, for example a sore throat, is actually not the virus itself, but the body’s immune response fighting the virus. In a way they are “good” symptoms. Symptoms such as diarrhea and losing one’s sense of smell are from the virus’s attack on the body, and could be seen as “bad” symptoms.

Those early symptoms being felt by a vaccinated individual, (and to a less reliable extent someone with a prior infection and some natural immunity), are usually while the person’s viral load is small, and there is far less pre-symptomatic spread. Whereas someone without antibodies nor memory cells is more likely to still have that period of being contagious prior to symptoms.

Anything I should take to cure the virus?

The great news is that we not only have the vaccines basically premedicating us with antibodies that fight the virus, but there is a highly effective medication. The most proven effective medication is Paxlovid, made by Pfizer. It is sadly collecting dust on shelves and being under-prescribed, with the guidance to give it to those at moderate or high risk.

The medication helps stop the virus from replicating/multiplying, so the earlier you are diagnosed, the earlier you can start the medication, and the more effective it will be. The latest you can begin taking it is day five.

In truth, everyone over the age of 50 and with any immunocompromise should be asking for it immediately upon diagnosis. I would also suggest that if someone is not vaccinated with a booster that they would be wise to ask for it, given their likely lower antibody level, but your doctor may refuse. (Please note: There are certain medications that prevent you from being eligible, unless they can safely be paused, as well as health conditions that rule you out, listed here, but your doctor can make that determination).

Should I get a second booster?

Currently only people who say they are immunocompromised, or are at least 50 years old, are eligible if it’s been four months since their last shot.

-If you are between 50 and 65 and have no health conditions, and you’ve gotten Omicron, I think it’s reasonable to wait for the new, updated versions of the vaccine that will hopefully be ready in a few months.

-If you have not gotten Omicron and are eligible, I recommend getting the second booster just to give yourself a fresh, high antibody count.

Keep in mind that every month your antibodies from the vaccine wane about 6%, but the beauty of each booster is that it not only refills you to peak levels, but your antibodies become smarter and more adept at fighting the virus, including variants. It is true that people who are vaccinated with boosters are still getting sick from COVID, but the ones with boosters have proven to have the best outcomes overall.

The vaccines haven’t been updated yet?

I will be the first one to shout that I am extremely frustrated with how long they have been dragging their feet on adapting the vaccine. Each and every year we know the flu shots will be updated with different strains, and even when they are not perfect, they still prevent a good amount of influenza; and what is not prevented is at least treated. And yet about 18 months after the vaccines were released, they still have not updated them to any of the new variants. Each mutation comes along and the vaccines continue to work a bit less effectively. People would be wise to keep up with boosters, not because the vaccine will prevent their illness, but because they still work nicely to premedicate them to fight the illness. It is also why getting a flu shot is prudent. From personal experience I can attest that if you get the influenza vaccination, it will give you a less severe case even if you still contract it.

They plan to have the updated versions of the vaccine for early Autumn. We just need it authorized for development and hope that the budget is approved for it to be available for wide distribution.

Is COVID ever going away?

Realistically, this is now endemic to our world, along with influenza and other viruses. I have always found it unfair to compare COVID to the flu, given how much more deadly it is. However, I believe that those who are vaccinated with boosters (and some with less predictable natural immunity) become more comparable to the risk of the flu.  I encourage everyone to get their flu shot annually, and I predict that I will likewise encourage everyone to get an annual COVID shot. I believe they will start to update them and some companies are already planning to create one shot that is for both the flu and COVID combined. That would be fantastic.

Any tips about other vaccines?

• Pneumonia vaccines are wonderful. I can’t tell you how many patients I see in the hospital with a pneumonia diagnosis. If you state you have immunocompromise, or are 65 or older, you can get those vaccines just like the flu shot, in your pharmacy. There are two that I recommend, but you should separate the timing of them by a year. Pneumovax 23 protects you from 23 strains of pneumonia. And recently they upgraded Prevnar 13 and came out instead with Prevnar 20, which protects you from 20 additional strains. Unlike the annual flu shot, in most cases you will only take these pneumonia vaccines once apiece and be done.

• Let’s understand TDAP better, another one you can get in any pharmacy. It stands for Tetanus, Diphtheria and Pertussis. We are used to getting this every 10 years because we grow up as children getting stitches along with a tetanus shot, and are told to get it again in a decade. It would be helpful to understand that pertussis, commonly known as “whooping cough,” is mostly harmless for adults, but can be very dangerous for babies. So when you are going to visit someone with a newborn, you would be responsible to be up to date with this vaccine. What you may not realize is that the pertussis part of the TDAP actually wanes after a few years, and even though they will tell you to get this boosted every ten years, I strongly recommend getting your shot every five years for the sake of the pertussis.

• HPV is a vaccine that had been mostly given to young women, and then men were eligible to get it through the age of 29, so I was never eligible. A few years ago however, they raised the age to allow men to receive the vaccine until the age of 45. To clarify, men are generally harmless carriers of the disease, but it is helpful to women if more men are vaccinated, and thus preventing the spread of this HPV which can cause cervical cancer.

• It is crucial that we understand and remember that while there are some vaccines that can entirely prevent you from catching the disease, many others including flu and COVID may not prevent it, but they will still give you a far better fight if and when you catch it. I believe that each of us will catch COVID and influenza throughout our lifetimes, but I am grateful that we now live in a time where we have ways to lessen the impact of these viruses when the time comes.