Our practice continues to follow strict masking protocols, since research has shown that primary care offices can be a site where patients acquire respiratory infections from the patients who were seen prior to their visit. In response to this data, we have chosen to limit our in office visits, to see anyone with respiratory infection symptoms outside, to sanitize between patients, and to provide any care that can safely be provided via telehealth or in outdoor visits on our porch for patients who prefer that, to minimize risk of transmission. We are no longer able to guarantee to leave exam rooms empty for 3 hours after each patient visit, however. We are sad about the changes in contact and connection that have resulted from these policies, but take that "Do No Harm" stuff seriously. . .
We encourage patients to continue to take measures to keep themselves and their families well, in this time of emerging new variants, and towards that effort are providing the following information:
There is no question that medical masks and other PPE (eye protection, etc.) are effective:
A review in the Lancet showed that transmission was lower by up to 82% with physical distancing of 1 meter or more, and was lowered as distance was increased. Medical face mask use (N95 or surgical masks) could lower risk by up to 85%.
There is also a Review in the Journal of General Internal Medicine that suggests that mask wearing results in milder disease if exposed, possibly due to exposure to a lower viral load at innoculation. As an example, the authors relate in the NEJM that the rate of infections being asymptomatic was MUCH higher (81% vs 20%) among those infected on a cruise ship where the crew and passengers were provided face masks than on ships where they were not, and similarly in food-processing plants where there was universal masking there were milder infections than were seen generally in the US.
Given the continued emergence of new variants of the virus, and the concerns that newer variants may be less thwarted by the earlier vaccines, I am recommending that people continue to mask when in indoor spaces with people not of your own household wherever feasible, even if you are fully vaccinated. I am as sick of it as anyone, but I think we all need to continue to do whatever we can to decrease transmission rates and to protect our hospital capacity, given how limited that is, the level of burnout among staff at St. Joe's, and so on.
N95 masks are the most effective - surgical masks are significantly less effective. Washable homemade masks are more effective if using tightly woven high thread count cotton, and fabrics with electrostatic charge, like silk and chiffon are best for blocking aerosols. Masks that have layers of different types of materials can be the most efficient. Whichever mask you wear, it needs to fit tightly against your face - if there are large gaps, you will be breathing around the mask, not through it, and no mask will work efficiently in those circumstances.
Goggles or face shields that cover the eyes appear to improve protection from exposure significantly, as high as 74% in one particular study.
I believe the current Vaccines approved in the US for protection against Covid 19 are both safe and effective. Within our own practice, we have seen that breakthrough infections tend to be mild and manageable, whereas our unvaccinated patients were much more likely to have severe infection and to be hospitalized or have long-term complications. It breaks my heart that so many of my patients continue to decline vaccination despite the large amount of data reassuring us that the risk/benefit is in favor of vaccination.
For those who are concerned that long-term side effects of the vaccines are not known, I would simply ask you to read some articles on long Covid - right now, the long-term side effects of the illness itself are so daunting, the milder risk of long-term issues from the vaccine pale in comparison. That said, I have seen tinnitus, an autoimmune skin rash called lichen planus, and multiple other complications from the vaccines themselves, and right now I am recommending an updated booster in the fall when new variants are targeted, but am ambivalent about the recommendations to repeat every 6 months.
It is increasingly clear that the mRNA vaccines are more effective in stimulating a robust and durable immune system response, so I recommend them in general, unless you have a specific sensitivity to polyethylene glycol or a previous mRNA vaccine. If you have underlying autoimmune disease, however, the Nuvaxovid (non-mRNA vaccine) may be less likely to provoke problems.
While the Moderna vaccine appears to be slightly more effective in preventing hospitalization and may therefore be preferred for older patients and patients with underlying health conditions, it also appears to cause more myocarditis and other side effects, and should be avoided in my patients under 30 years of age.
We know from studies on vaccination schedules in children that vaccination triggers a series of events in the immune system which are carefully choreographed and coordinated, and that administering a 2nd vaccine too early in the process while the immune system is responding to the 1st vaccine may decrease the effectiveness of the 2nd vaccine. I therefore recommend separating vaccine administration by 6 weeks when possible, and by a minimum of 4 weeks unless there is an emergency such as a tetanus exposure, in which case delay is not advised.
Practically:
If you need a flu vaccine as well as your Covid booster, for instance, get them on the same day, or separate them by 4 to 6 weeks.
Covid 19 has made it clear that staying healthy/taking care of ourselves can decrease the risk of hospitalization from acute infections as well as helping to prevent chronic disease. A number of factors, including stress level, diet, vitamin D status, and hours of sleep all have been shown to have an impact on the severity of infection if we are exposed.
Diet quality is strongly associated with the risk of severe Covid 19. Healthful Plant-based diets decreased the risk Of Covid 19 by 10% and of severe Covid 19 by 40% Compared to the Standard American Diet (SAD) in the original studies, and a 2024 study found that Plant-based diets were associated with a 39% lower risk of COVID-19 infection, another that there was a 38% lower risk of hospitalization.
Sugar-sweetened beverages increase the risk of hospitalization - 3 beverages per week increased the risk by 74%.
Sleeping fewer than 7 hours per night also correlated with increased risk of hospitalization.
Probiotics, Multivitamins, Omega-3 fatty acids, and vitamin D supplements appeared to decrease the risk of Covid-19 in women.
We are able to prescribe Paxlovid or molnupiravir for those at high risk of severe disease if we have a positive test within the first 5 days of illness, and have some other suggestions to control symptoms and lower the risk of long covid. Please call right away if you test positive, and please test even when it "just seems like a cold."
We also have pulse oximeters to loan to patients, so that oxygen can be monitored at home through the course of the illness.
There is also a study showing Olive leaf Extract can affect the course of hospitalized patients with Covid-19, and we think it may be influencing the risk of developing long covid in our patients.
For now, we think there are two different phases of this infection, and remedies recommended in each will be different:
My usual advice about Pelargonium sidoides (V-clear or Umcka) or Andrographis (immune-boosting supplements) MAY be appropriate although I am more likely to recommend the Olive Leaf extract these days.
I would recommend one of those along with:
Vitamin C 500 mg three times a day
Vitamin A 10,000 - 25,000 IU per day
Zinc 60 - 100 mg per day if tolerated without nausea - lozenges may be ideal
These doses should not be taken long-term unless you are also supplementing copper
Quercetin 500 - 2000 mg per day
Vitamin D 1000 - 5000 IU per day (more the higher your body weight)
Thyme steam inhalations -
Boil some water and pour in a bowl or mug. Add 1-2 drops of essential oil (thyme oil) and breath the steam for 5-10 minutes twice daily
AVOID STEROIDS
DO NOT CONTROL FEVER - allow temperature to be high(up to 103 degrees), because that may actually help your immune system control the virus
IFM also believes the following may be helpful for both phases:
Curcumin 500-1000 mg twice a day
EGCG - 4 cups green tea per day or 225 mg per day
Resveratrol 100 mg twice a day
Inflammation or "Cytokine storm" seems to be the problem, that is the immune system's reaction to the virus, so in theory things that boost immune response may be detrimental
->STOP Pelargonium (V-clear, Umcka), andrographis, Elderberry
Increase vitamin C to 1000 mg three times a day or higher, if tolerated
Continue D, Zinc, Quercetin - Quercetin study
Add magnesium 500 - 1000 mg per day if tolerated
Consider adding melatonin 3-6 mg at night(but may increase hallucinations/vivid dreams) -
Melatonin review
Thyme steam inhalations (see instructions above)
L-arginine 1.6 grams twice a day - May decrease the need for respiratory support - Arginine study
Inhaled steroids
Oral Steroids are helpful for inpatients and maybe in outpatients with severe disease
Ivermectin - this is no longer recommended against by the NIH; they do not recommend for or against right now because preliminary data suggests possible benefit Check out ivmmeta.com for a summary of data
Fluvoxamine may be helpful but is an SSRI(antidepressant) used at pretty high doses for this and I am concerned about side effects and have not prescribed this for this indication
There is a lot of questionable information out there, but one of the individuals who I absolutely trust to have researched his recommendations is Dr. Leo Galland - https://drgalland.com/
Through this whole pandemic, we have been needing to make decisions based on uncertain or inadequate information. If we do not have CONTROLLED studies, we may be tempted to give things that are harmful in our desperation. (For one historical example, check out the CAST trial - we were using a medicine to prevent arrhythmias that actually turned out to cause MORE sudden death.)
Evidence - half of patients were given X and half were given placebo, and the patients given X did better.
Anecdote - "so-and-so took remedy X and got better"
Please remember 80% of people have mild illness, 14% are severe, only 5% are critical. So most people will get better even without an effective remedy. Some may be getting better DESPITE whatever they are given, not because of it.
Some of my patients who are most suspicious of mainstream medicine are requesting things that are unproven and might be expected to be counterproductive or harmful. PLEASE do not try unproven things like nebulized peroxide (which I believe may be quite dangerous) without checking in with me. I will do my best to research what you are requesting and give you a science-based opinion about it.
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