Last Fall, we were anticipating the triple threat and another significant surge of COVID complications, but fortunately, both threats proved much less than anticipated.  In my county, we have improved from highly prevalent status to low prevalence of COVID.  Our hospital and ICU cases with COVID have also significantly improved.  This good news is tempered by the reality that in the USA we still have about 7,000-8,000 deaths each month attributed to COVID.  Nine out of 10 of those dying are > 60 y/o and some of these are up to date on their COVID vaccine.  

The federal government is ending the public health emergency declaration May 11 and California ended its declaration February 28.  This means we will have access to free PPE, Testing, Vaccines and oral COVID meds as long as the COVID stockpiles last.  It also means that most of the community testing and vaccination programs with easy access to the public are ending.  Free access at pharmacies will continue for those on MediCal.  We will be returning to the pre-pandemic model where local health care providers and pharmacies administer the COVID vaccines and PCPs/Foundations/FQs Centers will be responsible for early clinical diagnosis and prompt treatment.  Local Public Health Departments will be consultants to these providers and to our facilities, while repackaging outreaches to homebound, homeless, and underserved populations.  We are already receiving digital platforms of high quality actionable guidance from CDPH, which should continue as the endemic evolves.  SNFs should be working with their consultant pharmacists to streamline the process for vaccinating new staff and residents.  The new single dose mRNA Pfizer and Moderna vaccines should make this more feasible.  

The new omicron sub-variants are more immune-evasive and contagious, but fortunately, haven’t proved more aggressive.  Unfortunately, these variants are resistant to all available monoclonal antibodies, including Evushield, which had been given prophylactically to those who are severely immunocompromised.  Many in our population do have fairly good protection from serious illness due to vaccine immunity, natural immunity, or both (so called hybrid immunity).  We now have good evidence that the new bivalent booster further lowers the risk of serious illness in those who only have natural immunity.  

Despite this protection, our patient population commonly has risk factors for serious illness and needs further protection should COVID be acquired.  Experts uniformly recommend facilities assess each resident for risk and appropriateness for Paxlovid and develop a plan for medication alterations to allow it to be prescribed even by the on-call physician.  The FDA has approved its use without a positive test in recognition that early diagnosis and prompt administration of Paxlovid provides the best protection for our residents.  For more details see this ASPR COVID-19 Treatments: Information for Long Term Care Facilities.

On Feb 1, the Center for Care Innovations, Physicians for a Healthy California, and CDPH released a helpful FAQ for those prescribing COVID-19 Treatments which includes a warmline for provider questions, Monday-Friday, 6 am-5pm at 1-866-268-4322.

A free app just became available for smart phones and tablets that connects to the Liverpool COVID Drug Interactions Checker.  It's called COVID-19 iChart.   As a provider, I've found it easy to use and quite helpful.

For those of us who take care of independent living residents in a CCRC (Continuing Care Retirement Community) or in other senior congregate living settings, similar COVID-19 Plans should be developed.  This has nicely been summarized in the CDC’s COVID-19 Personal Plan Tool which is available online.  Besides providing understandable information on risk assessment, tests, treatment, test to treat sites, and prompt access to prescribers. This tool helps providers keep track of COVID-19 community levels, vaccine updates, ventilation measures, and masking guidance.

In my county, I suspect 30-40% of our residents are candidates for prompt antiviral therapy with the FDA indications being > 50 y/o, the unvaccinated, or those vaccinated with risk factors for serious illness.  I suspect this is true of most counties in our state and supports better public messaging and trust building so that personal preparedness plans become a normal part of living through this endemic. At a recent CCRC Town Hall meeting, I encouraged residents to contact their provider to set up a Personal COVID-19 Care Plan that includes early diagnosis and timely access to customized medication treatment.  Residents need to know that treatment is indicated even when symptoms are minimal.

As part of this messaging, we need to inform our staff, residents, families and communities that the approved oral agents remain effective without viral resistance and are not associated with “Rebound”.  Recent studies have found “Rebound” to be a normal part of COVID-19 illness in some people which lasts 1-2 days and then resolves.  The initial concern that Paxlovid was associated with “Rebound” has been disproven.  Those who are candidates for the oral antiviral medications should know that the earlier the treatment occurs, the better the outcome.  

AMDA, The Society for Post-Acute and Long-Term-Care Medicine has nicely stated the case for the above living with COVID plans in their Town Hall meeting of January 30, 2023, it’s freely available online. The last presenter, Dr. Leslie Eber gave a succinct approach to working with your staff, residents, and families to develop a collaborative culture encouraging decisions that are best for the community.  

As we move from pandemic care to endemic care, let’s take advantage of what we have learned and apply it for the benefit of our communities.