One million dead and updates on Paxlovid.

The U.S. passed a sad milestone yesterday as we identified the one-millionth person whose death was attributed to COVID-19. While I won’t get into the debate about whether these assignments were entirely accurate, the bottom line is that excess deaths from COVID-19 are probably close to that number.

In some ways the ongoing dribble of noise from the media has desensitized us to the magnitude of what has happened. If someone had attacked the United States with a bomb and killed a million people, or if there had been a natural disaster that caused a million people to die in a single city, the outcry would likely have been much different.

Regardless, it is clear at this point that this pandemic has taken an awful toll, which likely would have been much greater without the vaccines and therapies that have been developed.

Looking at current death rates and given the number of ongoing COVID-19 infections, we could easily have had one and a half or two times the number of deaths we’re seeing now, without the immunity from vaccines and natural infections and the development of drugs that markedly reduce the incidence of hospitalization and death.

That is really the only bright spot in this incredibly sad milestone.

I also wanted to give an update on Paxlovid, the antiviral drug now available to treat COVID-19. I mentioned in my Last Post that I had taken this drug when I was infected and found that it was very effective in reducing symptoms. Since that time the federal government has supported my perspective and called for wider access. As is usually the case, however, a couple of recent developments indicate that this drug is not a panacea. 

First, Pfizer performed a trial to see whether this drug could be used as a prophylactic medicine to prevent infection in individuals who had been exposed to COVID. While infections were reduced by about a third vs. placebo, it was not significantly better than no treatment. In a press release Pfizer Chief Executive Albert Bourla stated, “While we are disappointed in the outcome of this particular study, these results do not impact the strong efficacy and safety data we’ve observed in our earlier trial for the treatment of COVID-19 patients.”

The result of this study is not surprising because the drug inhibits an enzyme that allows the virus to multiply after someone is infected. This is very different from preventing an infection, as is done with vaccines. Pfizer would have markedly increased sales of the drug if it had worked as a prophylactic, so for them it was worth the risk. I do agree with Bourla this should not decrease the confidence in the drug as a treatment for COVID-19.

Another, more disconcerting issue with the drug has emerged. Individuals who have taken the drug report getting much better and clearing the virus quickly. Despite this, there are now stories that individuals re-develop symptoms a week later and then have evidence of virus in their nose.

Many of these “rebound” illnesses have worse symptoms than the initial infection and are disconcerting. Despite this, the reports have not indicated that they lead to any worse outcome from the infection.

Theoretically, the rebound could occur because there isn’t enough immunity built up to totally kill the virus after the antiviral drug is stopped. When Paxlovid treatment is ended and the suppression of the virus is removed, the SARS-CoV-2 starts replicating again and provides additional symptoms until the immune system finally kills it.

I can report that this is a real phenomenon since it occurred with my own infection. I finished the drug on a Monday and was totally well with no evidence of nasal virus for a week on daily antigen testing. Then, on the following Monday I had significant, recurrent nasal symptoms and was found to be antigen positive. This lasted for three days, which was longer than my initial symptom phase. I am now well with a good outcome after the infection, but it was surprising to me that the symptoms during the second round were so significant.

While the drug is not perfect, it does seem effective in suppressing symptoms and preventing hospitalizations. I have been told no one who has taken the drug has required hospitalization at our facility. Despite this, a longer course of therapy or other measures may be necessary to prevent rebound.