Edward writes:

I have been a longtime listener to TWIV and Daniel’s Clinical Updates.  I applaud the evidence-based approach you have promoted.  Your insights have been of great value to my clinical practice and also personally.  However, I have to take issue with Daniel’s interpretation of “Paxlovid Rebound”.  Daniel has repetitively stated that the “Paxlovid Rebound” is a manifestation of the T cell inflammatory response to the infection.  While this teleologically makes sense, I cannot find literature to support this position.  Rather, when searching Pubmed for ” Paxlovid Rebound”,  I find only one article theorizing that “viral dynamic models explain the rebound phenomenon, based on the idea that 5-day Paxlovid treatment started near the time of symptom onset reduces the depletion of target cells but does not fully eliminate virus, thus allowing the virus to rebound once treatment is stopped”.

According to an article published in the Annals of Internal Medicine in November 2023, viral rebound occurs in 1 in 5 patients receiving Paxlovid.  The accompanying editorial goes on to speculate that “The most compelling explanation for the relationship between N-R treatment and COVID-19 rebound is that 5 days of treatment at the current dosage is inadequate”.  The editorialists refer to the mathematical model mentioned above and state that ” early treatment with N-R leaves too many target cells susceptible to infection; incomplete suppression of replication-competent SARS-CoV-2 by N-R would be expected to lead to rebound”.

[Preprint]. 2023 Jun 1:2023.05.30.23290747

Edelstein GE, Boucau J, Uddin R, et al. SARS-CoV-2 virologic rebound with nirmatrelvir–ritonavir therapy. An observational study. Ann Intern Med. 2023. [Epub ahead of print]. doi: 10.7326/M23-1756

Cohen, M Ann Intern Med. 2023 Nov 14 : M23-2887

I would appreciate your comments.

Edward J Gold MD

Chairman of Medicine

Medical Director for Ambulatory Care

Hackensack, Pascack Valley Medical Center 

DJ writes:

Hi Vincent and Daniel!  Thanks for all you do!

I’m a retired band director who does a lot of substitute teaching in schools with lots of newcomers to North America.  In the run-up to covid I was out buying hand sanitizer and cold medicine already in February (I’m a bit of a nervous nellie).

What precautions should I be taking regarding mpox?  It’s not spread respirally (Is that a word?) but in the band room there’s plenty of spit around.  Hand sanitizer? gloves?  I would appreciate your thoughts.

Incidentally, I’m triple-vaxxed and a No-vid (at least as far as tests can confirm), which I laughingly chalk up to having been exposed to every possible germ during 40 years of teaching little spit-factories.

D.Jay

Ellen writes:

Twice now I’ve heard that doctors are telling their patients that Paxlovid is not that effective against the current strains of covid for people over 65 with or without underlying conditions. Is this true?  If not, where are doctors getting this information? These are reputable doctors in Progressive cities who I wouldn’t think are susceptible to misinformation.

Thank you for what you are doing that is priceless for ordinary folks like me.

Ellen in New Mexico 

Rich writes:

Thank you for your efforts.

Is there any indication that long COVID can result after an asymptomatic infection?

Rich

Carrie writes:

Dear Dr. Griffin,

I may need to travel to urban and rural Kenya for work. I am a middle-aged female, mostly healthy, except for a type of autoimmune arthritis, so any infection could cause a flare, which can be debilitating. I am looking forward to getting the updated Novavax vaccine when it’s available. Given the latest Mpox outbreak and potentially staying in hotels with questionable housekeeping, being on planes and in crowded locations, and having limited access to quality healthcare, getting an Mpox vaccine (and traveling with Paxlovid) seems to make sense. What is the optimal sequence of getting Novavax and the Mpox vaccine to ensure an effective immune response to each vaccine? So far, I’m not on biologics, so I think I would generate an immune response to both vaccines.

Thanks for all the work you do!

Carrie