How to handle a third summer with COVID-19

We’re heading into a third summer with COVID-19 and a lot of people are finding it hard to assess their risk in this new stage of the pandemic.

Most of Minnesota, including the Twin Cities, seems to be coming out of a small surge, but cases are rising in southern Minnesota. 

By now, two thirds of Minnesotans have had at least two doses of a vaccine. Even more have likely had the virus. The CDC estimated in April that almost 60 percent of people had been infected. Other studies put that number higher, and it’s sure to have gone up with the recent waves of infection.

But, we also know that being vaccinated or recovering from COVID-19 once doesn’t protect people from getting it again. New strains keep popping up. Wastewater samples from the Twin Cities show that people now are spreading a third version of the omicron variant that hit in January. 

More than ever, our individual risk of catching the virus or falling ill boils down to our individual situation.

MPR News host Angela Davis spoke with Minnesota Health Commissioner Jan Malcolm and infectious disease expert, Dr. Greg Poland, about the risk of variants, masking advice, when to time a booster, new vaccines coming in the fall and how to cope with a virus that isn’t going away. 

Below are highlights from the show that have been edited for length and clarity. Listen to the full conversation by clicking the audio player above.

When you look at the most recent number of cases in Minnesota, how do you describe what they show? How are we doing?

Malcolm: It's even hard to count how many waves we've had now and some of the waves really never ended before the next one kicked in. Certainly, over the last couple of months, we've seen cases going back up but at a slower rate than we did with the original omicron strain in December and January.

We've watched this kind of slow build. I think thanks to vaccination and boosting and treatments, hospitalizations have not risen to the same degree. Over the last week or two weeks, we've seemed to be stabilizing a bit.

What about deaths?

Malcolm: We have been grateful that we haven't seen as many deaths in this most recent wave. We’ve pretty much been in the single digits. Still, we've lost over over 12,600 Minnesotans over the last two years. Even when we're having five and 10 deaths a day, that's five and 10 too many.

Dr. Poland, how about you? Are you seeing reasons for us to be optimistic now or not? What do you see in how we're doing right now as a state?

Poland: We seem to be divided into two categories: People who believe in science, who believe in the effectiveness of public health measures. And those that don't. Those that I would say, sort of live in a world of hesitancy, doubt and rejection of the scientific method.

And so, you see nationwide, it's almost hard to say, almost unbelievable, that since COVID started, one out of every 320 Americans is now dead of COVID. Over a million people, more than we had during the 1918 influenza pandemic. So, as a health care provider you're caught in this odd world where I go into a room and especially early on people were saying, “When can I get the vaccine?” Now we'd go into a room and say, “I notice you haven't had the vaccine.” (And they say) “I don't want that. That's dangerous.”

The problem we're having now is really a complex matrix of time since last booster, the development of new variants and psychological human issues. “COVID fatigue,” as it's being called, should have no rational place in deciding what do I do to protect my life and the life of my family and my community members. And yet, in Minnesota and elsewhere, the majority of people are pretending that the pandemic is over. It is not.

For example, during the omicron wave we’ve just come through, we had more people die in four months than we did with six months of delta last year. That's stunning. We should have learned as a population that wearing masks indoors makes a lot of sense. Social distancing makes sense. Getting my vaccine and my booster makes sense. And yet we've got a sizable minority that doesn't believe that and don't follow those recommendations.

Caller question: Some in my family are getting over their first bout of COVID, but others in the same household continue to test negative. Why? And what should we do to stay safe this summer?

Malcolm: The pattern of who gets it and who doesn’t can be a mystery. One of the most important things that we can do at this point is to stay up to date with vaccines and the boosters. It's very clear now that these new variants can evade immune protection, whether that's from a prior illness or from a from a shot that has worn off.

I really appreciate how Dr. Poland laid out the logic case. There’s a lot of virus out there, certainly outdoor environments are much safer. But when you're in an indoor environment around other people, you might just as well expect to that you're going to encounter folks who are infectious. So stay up to date with those boosters and wear masks indoors.

Poland: One thing to remember, when we talk about evasion of immune response, it's not that there's no protection, it's that each of these new variants requires higher levels of antibody to perform an actual lower level of neutralization. So your age, your medical condition, your genetic background, the time since your last vaccine and which variant is circulating, all play a complex role in in determining this.

There's no strict time limit or time interval between when you got infected and when you get your booster. In general, I'd let you recover and wait a month or so and then get the booster as recommended.

What do the new variants mean for our chances of getting reinfected?

Poland: Let me be clear to the point of maybe being blunt: If you're not somebody who has been immunized or who's wearing masks indoors around people who are not your family, you will get infected, and you will get infected repeatedly as new variants arise.

These variants will continue to arise as long as large numbers of people are getting infected. And that will occur through both mutation and what's called recombination. That is what these RNA viruses do. I've studied them for almost 40 years. And this is playing out exactly as you would predict, given the distortion of human behavior happening in the context of a worldwide pandemic.

For people who have recovered from the virus recently, how long are we protected from getting it again?

Poland: I could have told you the answer to your question with omicron, which is almost certainly what you got infected with. I don't know the answer to your question in the face of BA.2.12.1. I particularly don't know what the answer to your question is should BA.4 or .5, currently ravaging South Africa, spread here. It's changing so fast that it is almost impossible to develop the scientific data fast enough.

How do we time our booster shots if you’re trying to stay fully vaccinated?

Poland: If you tested and it was positive, we would consider that the equivalent of a booster. Now, what's going to happen is sometime this summer, we are expecting a variant focus booster. That'll be important because for the second booster the recommendation is based on two pieces of data, both from Israel.

One showing that (the variant focused booster) decreases the risk of death by about 78 percent. Now stop a moment to think about that. What that means is you reduce your risk from .1 percent to .03 percent. A measurable real difference, but a real fractional one. Why? Because you are gaining the value of the previous three doses that you got.

It reduced the risk of severe or serious illness by about two-fold and moderate illness by about that same amount. But that effect only lasted four weeks, and by eight weeks was gone, highlighting the need for updated boosters, or so called variant focused boosters.

Caller question: I was exposed to COVID, had a negative test, I’ve had one booster. What’s my quarantine protocol?

Malcolm: Those are difficult decisions. The abundance of caution is still advised even if you’ve tested negative. I’m guessing you used a rapid test, which are optimal when you use them for a couple of days in a row.

Poland: If you have no fever or symptoms, then what I personally would do would be to consider going, but wearing a proper mask properly. Like a KN95, or 94. And wear it properly, crimped around your nose, no air spaces around your face, not below your nose, not below your chin, as you see so many people doing. And maintain some physical distance. That way, I think you're probably protecting other people should you be harboring an asymptomatic infection.

Caller question: What’s on the horizon for vaccines?

Poland: We will likely have a vaccine recommendation for children down to six months. I can tell you definitively that, for example, Moderna has done studies looking at a combination COVID and influenza vaccine. The real triple winner is the idea of making a COVID, flu and RSV (respiratory syncytial virus) vaccine. All of those are being worked on. Whether they would get through the approval process in time for the beginning of this flu season is anybody's guess. We'll get them eventually but I don’t know how quickly.

What do you want people to know about long COVID?

Malcolm: We're just now starting to get a little bit better data. Potentially, 20 plus percent of all people, depending on age and underlying conditions, who even who had a very mild case, can come down with long-term complications and a very confusing array of symptoms. I don't think we even know yet the full extent of organ damage and other things that might be happening.

So there's a lot of work to do to support people who have long COVID and to support clinicians who are trying to help them. Certainly, a lot of the actual clinical research will be done at the national level, but here at the state level we are working get better educational information out there to folks about resources that might be able to help.

Poland: We know that about 60 percent of the long COVID cases are in females. Why is there a disproportionality? We know that it is more likely to occur in young to middle ages, not so much in young kids. Not as common in elderly. We know severity has something to do with it. We know that it can be in part prevented by having gotten prior immunization.

And the public does not understand this well, because they tend to track on “well, you know, my next door neighbor had it and she didn't die.” Here's the problem with that kind of thinking. The risk of a subsequent mental health diagnosis goes up 40 to 60 percent. The risk of subsequently developing Type 2 Diabetes, even after a mild case goes up 40 percent. The risk of some 20 different cardiovascular diseases for the next year goes up considerably.

This is not a benign flu-like infection. It has consequences that we don't generally see.

When will a vaccine be available for babies and toddlers?

Poland: So the plan is that the FDA is going to meet in mid-June. They're going to review a Moderna and a Pfizer application. The Moderna application is going to request a 25-microgram dose that's one-fourth the adult dose, and there'll be two doses roughly a month apart. And this will be for kids six months to five years of age.

Pfizer's going to ask for approval for a three-microgram dose. Remember, the adult dose is 30, so one-tenth of it. But they will get three injections at zero, three weeks and 12 or more weeks after the second dose for kids 6 months to 4 years old. The Moderna study, we don't have full data on, but it shows about a 40 to 50 percent reduction in symptomatic disease. The Pfizer data show about an 80 percent decrease in symptomatic disease, at least during the omicron outbreak. How either of these will operate in the face of future variants is unknown.

If the FDA meets in mid-June and if they approve it. If it then goes to the CDC and the CDC approves it, by early July, kids would be able to get the vaccines and complete, at least in the case of Moderna, the full series, and in the case of Pfizer have the three doses prior to going to school.

Caller question: Could I have my antibodies measured and use that as a marker of whether I am protected?

Poland: The answer to that is generally no. And the reason for it is we don't know what level of antibody protects you against what complication of the disease or even against infection.

Obviously, the higher the antibody level, the better. If there were no antibody or if it was very, very low, we might have some level of concern. But remember that that level of protection is going to vary by which variant you get infected with. So we do not have, the formal name for it is, a “correlative protection.”

How has testing changed over the past few months?

Malcolm: We do continue to offer both rapid testing and PCR testing at a number of state sites. We want to make sure that whether they're tests at pharmacies at health care providers, or other kind of community locations, that everybody around the state has access to tests.

You are able to order online free tests from the federal government as well as from the state. And currently, while we're in a federally declared public health emergency, insurance companies have to cover the cost of tests without copayments, up to eight per month.

And testing does remain important. People can protect themselves and others if they know their status before they are doing something social, are going to a big, eagerly awaited event. Testing continues to be one of the tools in the toolbox. It's good idea to have a supply of rapid tests at home for that kind of use.

What can you tell us about the new antiviral medications?

Poland: In terms of treatment, there are four things that can be used Paxlovid; remdesivir; which is administered intravenously; one monoclonal — we only have one monoclonal now that we can use to treat because the variants have outwitted it; and, then a third antiviral, Molnupiravir.

Paxlovid is the one that you most hear about. There's difficulties in accessing it. I think we should make it easier. It's generally for people who are moderately to severely immunocompromised or people 65 and older who have a positive test and are at high risk of complications.

You have to take it for five days. There's beginning to be some concern of so-called Paxlovid rebound, which means we may have to treat people longer than the normal five days. And the one difficulty with it that is there are a large number of medications, herbs and supplements, that you cannot be taking while you take Paxlovid. What's the value of it: about an 89 percent efficacy in preventing death and severe disease.