Five Things To Do When You Get COVID

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• YOUR GUIDE TO FALL/WINTER VIRUSES & VACCINES

• What’s next with COVID: My conversation with public health expert Monica Gandhi, MD, MPH

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📣 NEW! AUDIO VERSION OF TODAY’S NEWSLETTER 📣

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I’m seeing an uptick in COVID cases among patients. This matches the national trend. The good news? Despite an increase in cases, COVID hospitalizations are not spiking. This is because the vaccines and past COVID infections both help reduce the risk of severe COVID outcomes.

The power of vaccination and past infection

Recall the vaccine’s best feature: its ability to reduce the risk of serious COVID outcomes, e.g. getting sick enough to require hospitalization. Recall that the COVID vaccines have been pretty weak against infection ever since the Delta variant arrived in spring 2021. The risk of infection may be diminished from two weeks to two months after a vaccine dose or an infection, but you can get 10 COVID shots (please don’t!) and still get COVID again and again. 

However, the vast majority of people who get COVID after vaccination or a past COVID infection (or both) don’t end up with severe enough disease to require hospital care. This is thanks to our T cells, the arm of the immune system stimulated by the vaccine and by past infection.

Photo by Hakan Nural on Unsplash

Don’t make the perfect the enemy of the amazing

Of course some patients will always remain vulnerable to serious COVID outcomes requiring hospitalization. Well before COVID existed, respiratory viruses like flu, RSV, and even “common cold” viruses like rhinovirus and adenovirus posed unique risks to elderly, frail, immune-compromised patients and to patients with certain underlying health conditions.

We cannot eliminate the risk of COVID; we can, however, help people understand their risk and how to mitigate it. For some people, that means getting another COVID booster this fall. For others, it means skipping another booster and working to better control their diabetes with medication, diet and exercise.

I am a huge fan of the COVID vaccine; I’m a bigger fan of helping people frame risk. 

5 THINGS TO DO WHEN YOU GET COVID THIS SEASON:

1. Don’t beat yourself up. 

Getting COVID is not a moral failure. The virus is ubiquitous and wildly contagious. The only way to avoid the risk of ever getting COVID is to seal yourself off from the world in perpetuity, so don’t shame yourself for living your life!

2. Consider testing.

Confirming the diagnosis of COVID is important if that knowledge changes medical management.

• Rapid home antigen tests (i.e., RATs) are highly sensitive for contagious levels of virus. If you’re sick and test positive on a RAT, two things are true: 1) you have COVID and 2) you have enough virus in your nose that you are contagious. If you are sick and test negative on a RAT, either 1) you don’t have COVID or 2) you do have COVID but not enough virus in your nose to be contagious. 

• PCR testing for COVID is appropriate if you’re sick, you have a negative RAT, and a COVID diagnosis would change management. A positive PCR test might mean a prescription for Paxlovid or notifying a high-risk loved one that they were exposed. If your doctor can run a PCR test for COVID, flu, RSV, and other viruses all in one swoop—even better. Because these viruses mimic one another, for patients in whom a diagnosis is important, PCR testing can help direct treatment.

3. Stay home from work or school. 

The best way to reduce the spread of a virus is to avoid close contact with other people when you are actively sick. Most vaccinated and/or COVID-recovered people are contagious for about 3-5 days after the first symptom onset, but the degree of contagiousness varies widely.

• How long should you stay home? For any respiratory virus, I usually suggest waiting until your symptoms are improving and you have been fever-free for 24 hours without the help of fever-reducing medications. The CDC recommends staying home for a minimum of 5-10 days for COVID, depending on symptom severity, and wearing your mask through day 10, regardless of the trajectory of your recovery.

  (You might be interested in contrasting the U.S. CDC’s guidance with the UK’s Chief Medical Officer’s advice to parents: “It is usually appropriate for parents and carers to send their children to school with mild respiratory illnesses. This would include general cold symptoms: a minor cough, runny nose or sore throat. However, children should not be sent to school if they have a temperature of 38°C or above.”)

  If you want to be more precise, recall that RATs essentially are “contagiousness” tests. A positive RAT means you are likely contagious; a negative RAT means you are likely no longer contagious. As such, RATs can more elegantly guide your period of isolation.

• Should you or your household members wear a mask when you’re sick at home? The totality of evidence on masking suggests that masks can work to help protect the wearer from infection more than they can protect against transmission. So, household members who want to reduce their risk of infection might might opt to wear a well-fitting, high-grade mask when they’re close to you indoors. It is certainly possible that wearing a mask when you’re actively sick sneezing, coughing, and/or feverish) can reduce the chance of sickening others, but better than masking to protect other people is staying home until you’re on the mend!

4. Treat your symptoms. 

I usually recommend over-the-counter Ibuprofen or Acetaminophen for body aches and fever, Delsym or Robitussin for cough, and Fluticasone or other steroid nasal spray for nasal congestion, only as needed. Of course these recommendations will vary and depend on the person.

• What about Paxlovid? Paxlovid has been shown to reduce the risk of serious COVID outcomes for unvaccinated patients. The randomized controlled trial (RCT) looking at Paxlovid in vaccinated people showed no benefit in reducing the risk for hospitalization. (This makes sense given how well the vaccine works against serious COVID.) I do prescribe Paxlovid in vaccinated patients, however, for its potential to reduce the risk of long COVID. A cohort study showed that when given to people with at least one risk factor for severe COVID outcomes within 5 days of a positive COVID test, Paxlovid reduces the risk of long COVID by 26%.

• What about Metformin? Metformin is a medication used to treat diabetes, pre-diabetes and insulin resistance. In a large RCT of patients with obesity or overweight, Metformin reduced the risk of long COVID by more than 40% when given within 7 days of symptom onset. (Note that a meta-analysis of 12 observational studies showed that even a single dose of the COVID vaccine prior to a COVID infection reduces the risk of long COVID.)

5. Know that recovering from COVID “naturally” boosts your immune system. 

When your immune system “sees” the actual virus, it mounts a sophisticated response in order to: 1) help you recover and 2) create memory cells that will spring into action when you’re next exposed to the virus. Getting COVID itself arguably gives broader protection against new variants down the road than the vaccine does.

So, how long after infection should you consider getting another booster? It looks to me that we should wait 6 months after infection or vaccination. Of course there are no right answers here—which is why it’s critical to understand the medical data and how it applies to your situation and to talk with your own doctor for nuanced advice. Here is an excellent review of who should receive boosters and when, written by public health experts Shira Doron and Monica Gandhi.

I look forward to watching the ACIP meeting tomorrow where recommendations will be made about COVID boosters this fall.

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Disclaimer: The views expressed here are entirely my own. They do not reflect those of my employer, nor are they a substitute for advice from your personal physician.

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