Manage BA.2—And Our Expectations
I’m seeing a lot of COVID right now. The Omicron BA.2 “wave” has fully arrived in DC and around the country. Most of my patients are vaccinated and, when symptomatic, tend to test themselves at home with a rapid antigen test. Then they call me to discuss what’s next.
Here’s the latest on BA.2 symptoms, testing, isolation, treatment, and prevention of severe outcomes:
Symptoms
This variant is wildly contagious but is not causing more serious disease than BA.1 (BA.2’s cousin) in the same person. Of course the same people who were at higher risk for severe COVID are still at higher risk for severe COVID: largely people who are unvaccinated and/or not immune from past infection—and people who have significant underlying medical problems and/or advanced age.
However, most people who are vaccinated and boosted (if eligible and appropriate) are getting cold- or flu-like symptoms—or no symptoms whatsoever—when they test positive. Some people have called their symptoms “mild”—nasal congestion, sore throat, and headache. Other patients have told me it’s the worst they’ve felt in years. Indeed there is nothing “mild” about being in bed for a week with chills, body aches, cough, and chest tightness. Fortunately the risk of serious illness for vaccinated and boosted patients—and for healthy young people even if not immune—remains extremely low. This is exactly why vaccination is critical for older people and those with immune deficiencies and underlying medical conditions.
In addition to COVID, I’m seeing a flurry of non-COVID colds, sinus infections, and coughs. I had two patients test positive for influenza A last week. It feels like 2019 all over again! By the way, this is not so much happening because we have dropped mask mandates; it’s happening because Omicron is wildly contagious, people are mixing more and more, and because of a phenomenon called “viral interference” where the predominance of COVID over the last two years forced other pathogens into relative hiding. Even people who mask in all public places are still getting COVID!
The upshot? These “bugs” can look a lot alike—nasal congestion, sore throat, headache, body aches, cough. So the best way to distinguish between the flu, RSV, other common cold viruses, and COVID is by calling your doctor and with testing. In the meantime, don’t assume your cold is just a cold and go to work or school!
Testing
The rapid antigen home tests continue to do a great job detecting infectious levels of virus. As I have been saying since July 2020, rapid antigen tests are “contagiousness” tests. If you test positive, not only do you have an infection with SARS-CoV-2, you have enough virus in your body to infect other people. Rapid antigen tests can remain positive (meaning: people can be at risk to other people) for up to 14 days, but most vaccinated people aren’t contagious after 5 days. Recall, too, that even without symptoms, people can test positive on a rapid antigen test and be at risk to other people. Recall that “asymptomatic transmission” is the very reason this virus has caused international pandemonium: non-sick people can sicken others.
Isolation
After a positive test (whether it’s a PCR or rapid antigen test), ideally you would isolate from other people for 5 days, starting from the day of the positive test or symptom onset (whichever came first). That is the CDC’s advice. I go a step further with my patients and suggest only leaving isolation after a negative rapid antigen test at day 5. If positive at day 5, isolate another day and test at day 6, and so on.
What about isolating from people who’ve had Omicron already, say between December 2021 and March 2022 (i.e. with BA.1)? Aren’t they already immune? The answer is probably yes. It looks like the immune protection from a past BA.1 infection offers protection against BA.2. In other words, if you have BA.2 now and your household had BA.1 earlier this year, it is probably okay not to isolate so strictly. I personally have not seen reinfection from Omicron but of course it is possible and has happened.
Treatment
Most of my vaccinated and immune patients are managing their symptoms at home pretty well with Ibuprofen, Tylenol, other over-the-counter medications, hydration, and rest. My asthmatic patients generally have needed their inhalers more during COVID—like they typically do with other respiratory infections. Of course treatment decisions are nuanced and should be made in consultation with your own primary care provider.
While it’s tempting to “just do something,” the evidence is clear that there’s no benefit to zinc or vitamin D supplementation, Azithromycin, or Pepcid or other antacids in treating COVID.
I have, however, been prescribing the oral antiviral medication called Paxlovid, indicated for people who are at high risk for serious COVID outcomes. Note that Paxlovid is only approved for people at high risk and isn’t needed or appropriate at this time for vaccinated and boosted people who aren’t high risk. The immunity your body has made in response to the vaccine is doing the work! Moreover, the immunity we get from an infection with SARS-CoV-2 itself provides added protection against future variants. In other words, it is your booster shot!
Down the road, we may learn that Paxlovid is safe and effective for average-risk patients, perhaps to reduce the duration and severity of COVID symptoms, but that research has not yet been revealed. It’s coming!
Meanwhile, Dr. Paul Offit, advisor to the FDA and vaccine expert, wrote this fantastic article for the New England Journal of Medicine last week about managing our expectations for what the vaccine can and cannot do, reminding us that we cannot eliminate the virus or expect a COVID-free existence—and that getting milder disease is not a vaccine failure but rather a vaccine success story. I highly recommend reading it!
Also last week, I explained how I’m advising my patients with Omicron this spring to WJLA in DC. You can watch the clip here.
The other common COVID symptoms?
Guilt, disappointment, fear, and shame. Especially for my patients who have stringently followed COVID protocols for two years, a diagnosis of COVID can feel like a moral failure. I fully empathize with this. We have sacrificed so much over the last two years to protect ourselves and others from the ravages of this horrible disease. I myself was a proponent of lockdowns back in spring 2020. Before vaccines arrived, perhaps like you I missed funerals and family events and kept my kids under lock and key.
So when my patients get COVID in spring 2022, I reassure them that getting sick isn’t a reflection of their character; it’s a sign of our time. Omicron is a ubiquitous and highly contagious variant, and unless we are willing to perpetually lock ourselves down, an exposure to it (or the next variant) is inevitable.
This is NOT to suggest we should give up, throw in the towel, or toss caution to the wind. NOT AT ALL.
I’m simply suggesting that in April 2022 there’s only so much we can do to prevent an exposure and to limit transmission to other people. We can and should do those things. We should get vaccinated and boosted if eligible. We should work on our underlying health conditions. We should care for other people by staying home when we’re sick and by releasing ourselves from COVID isolation only when a rapid test is negative and at least five days have elapsed. We should ask our doctors for Evusheld if we’re immunosuppressed. We should help our elderly family members ensure they have access to Paxlovid if and when they need it. If we want or need added protection, we should mask up with a well-fitted, high-grade mask, knowing that one-way masking offers another layer of protection.
But we cannot seal ourselves off from the world in perpetuity. That itself isn’t healthy. The harms of ongoing pandemic restrictions aren’t zero, and they’re increasingly obvious. I see them every day in my patients—from the natural anxiety about the virus itself to the emotional toll of social isolation (particularly in my teenage and elderly patients.)
This weekend I flew back and forth from the UK. I’m actually writing this newsletter from Heathrow airport where the people-watching is great. All different shapes, sizes, races, ethnicities, (visible) abilities and disabilities. Masks are optional. (About fifty percent of people are masked.) Lots of hugging, multigenerational families who look to be reuniting for holidays.
Joy. Tears. Baby bottles, moms bouncing infants, older men in wheelchairs. I’m currently observing a large extended family with kids and perhaps two grandmas (?) in beautiful saris, all unmasked, sitting next to another large family, all masked. No one is judging. It’s families being families.
It’s reality. People are doing what they think is appropriate, and it’s great. I would no more assume that the unmasked folks are *uncaring* toward other people or that the masked family are *overly anxious* than fly to the moon. (It’s also not my final destination.) My mind isn’t even on COVID. It’s about the war in Ukraine. It’s nostalgia about my own kids being grown. Babies are so smiley and innocent.
We have varying health and human needs. We have diverse risk tolerances. We’re doing what we can. Let’s judge and shame less. Let’s give each other some latitude and grace. We’re all adjusting.
I will see you next week. Until then, be well.