Back in July, I wrote an email titled, “It’s time to stop being afraid of COVID,” which was essentially meant for the many patients, family, and friends I know that were still restricting many of their usual activities due to fear of COVID.  The quick summary of that (also long) email was that while early in the pandemic, getting COVID was serious and potentially fatal, currently with all the tools we have  (vaccinations, boosters, home testing, and oral treatments like Paxlovid), COVID is really no more than a bad cold for vaccinated people, even for those at high risk (older than 65, heart disease, diabetes, etc.), and that even those at risk for severe COVID disease,  the risk of dying from COVID is 1 in a million or less, which are similar to risks we take every day (riding in a car, crossing the street, etc.).  The purpose of this email is to go one  step further, focusing on the importance of getting back to normal, and more importantly how to do this, specifically for those  who still have major concerns.   First,  some data recently published in the New York Times seen in the chart below shows hospitalizations and death rates in King County, Wash., which includes Seattle, who publishes some of the most detailed, up-to-date COVID statistics in the country.  This data shows that the vast majority of hospitalizations and deaths are in those who are unvaccinated.  The risk of hospitalization for a vaccinated senior is less than 1 in 50,000. The risk of death for a vaccinated, boosted senior is 4 in 1 million. This of course doesn’t include those who have gotten multiple boosters, those who have access to a primary care physician and thus easy access to Paxlovid if needed, and of course doesn’t include the new bivalent vaccine.   Adding these factors to this robust and recent data, I stand firm that even if you are at high risk, if you are vaccinated and boosted your risk of dying from COVID is less than 1 in a million, which again is much lower than things we do every day. However, no matter how much reassuring data I present, there are going to be some patients who are still nervous.  They don’t want to get sick, and they are worried about things like long COVID (which I will get to in a minute).  Thus, it’s important to spend some time on the consequences of not getting back to normal.      The pandemic has taken a huge toll on our society.  My wife is a substitute teacher in Montgomery County, and she has seen first hand how behind our children are from missing  in-person schooling.  These deficits are not just merely in reading and math, but also involve things like social interactions and emotional issues.  The same is true for adults.  We are social beings by nature.  We need to be out and about, engaging with other human beings.  If we are not able to see our friends and family, or do the things we enjoy like going to restaurants or shows, this takes a huge emotional toll.  I have seen this first hand with several of my patients.  There are also physical consequences, such as poor sleep and lack of exercise, which can lead to worsening of chronic conditions or the development of new ones.  I have also seen issues with couples, where one spouse is overly worried and/or careful and severely restricts the activity of their spouse. This can be detrimental for both individuals, and strain the relationship.  Given the incredibly low risk of severe COVID consequences even for those at high risk, and the significant emotional and physical consequences of restricting activities due to COVID, I strongly recommend that everyone get back to doing what they used to do before the pandemic.  Below is a list of how to do this in such a way that even those of you who are still nervous can feel comfortable doing so.   Safely going to restaurants, shopping and other public events (theater, sporting events).   There is no way to completely avoid getting COVID.  Most Americans have been infected.  Even Biden and Fauci got COVID.  However, minimizing exposure risk where possible can be a reasonable way to continue normal activity.  Currently, numbers are low, so I do not currently recommend masking other than busy, crowded, indoor places (airports, airplanes, a crowded bar).  While you can eat at a restaurant outside, this will be harder to do as the weather turns colder.  So, for those of you that remain concerned, you can wear a mask indoors at a restaurant and remove it when you are seated.  Unless the tables are squished close together, your chance of getting COVID from diners not in your party is pretty low.  If you want to mask up for the bathroom and when leaving, that’s OK.  Outdoor public events and places, even when crowded, should not require a mask.  However, if you want to wear a mask at a theater or even in the grocery store, that can reduce your risk.  Again, while I don’t think this is currently necessary, for those who are worried it would be better to mask when shopping than never get out of the house.   Now, should the numbers start to climb again, wearing a mask in public places and even avoiding crowded public indoors may be reasonable, but until that time, please resume all routine activities.   Visiting with friends and family This may be one of the most important activities that can have a severe emotional impact if not resumed.  You should see friends and family, at their homes or yours.  You should have Thanksgiving dinner.   Contracting COVID depends on a variety of factors: level of virus in the community, ventilation, and proximity to others.  Given current low levels, even having a small number of friends and family indoors, even without masks, presents a very low level of getting COVID.  For larger gatherings, risk is slightly increased.  However, in these situations, given the wide availability of home testing, it is not unreasonable to ask people to test before a larger gathering.  Again, while this may not be necessary when levels are low, it would be better to ask people to test and enjoy an unmasked gathering, then not get together at all.   Getting the new bivalent booster As stated above, risk of serious illness and death from COVID has largely been eliminated due to vaccinations and boosters. What has been incredible is that up until now, vaccines and boosters have been based on the original strain of the COVID virus, which we haven’t seen for years.  The current predominant strain has been Omicron, which the bivalent vaccine contains.  While I can’t prove that this new vaccine will decrease symptoms or prevent more deaths, it is more likely to do so than not.  Also, for those who were skeptical due to the lack of initial human trials before being approved, the new bivalent vaccines have now been taken by millions of Americans and there have been no reports of anything different or unusual from the regular vaccines and boosters.  I urge all individuals who are eligible to get this new bivalent vaccine.   Contact your doctor if you get COVID I have previously discussed my re-thinking of Paxlovid, and not using it automatically in every infected patient at risk.  This is primarily due to the fact that for most patients who are vaccinated and boosted, even for the elderly and others with at risk conditions, symptoms are mild and risk for serious illness is low.  In addition, there are some side effects, medication interactions, and risk of prolonging the disease with Paxlovid.  However, Paxlovid does remain an important tool in fighting COVID, especially for the few patients that might get severe symptoms.  Since Paxlovid can be given within 5 days of the onset of symptoms, waiting a few days before starting Paxlovid to see how things progress or improve is likely the best approach. Thus, I recommend that if you become ill with COVID, contact your doctor as soon as possible in order to have a plan in place should Paxlovid become necessary.    Preventing getting infected with COVID While the above methods describe methods to make normal activities safer and decrease your risk for serious illness if you do get sick, one of the biggest barriers to resuming normal activities for many is not wanting to get sick in the first place and fear of getting long term complications like Long COVID if they do become infected.  Fortunately, there is now some evidence of things you can do that prevent both of these situations.   Nose sprays: There are several nose sprays that may be useful in the treatment and prevention on COVID19.  One is called nitric oxide, which in one small study showed it could reduce the amount of virus in the nose, and is currently being evaluated in larger trials.  Unfortunately, it is only available in Israel.  The second is Xylitol, which is a natural sugar alcohol found in plants,  and can also reduce the amount of COVID virus, thus preventing infection.  It may even reduce symptoms.  Fortunately, this is available in the US, and is called Xlear, available in most retail pharmacies, and on Amazon for about $8.   Vitamins: There is strong evidence that certain vitamins and supplements, based on their antiviral, antioxidant, and immune boosting properties that can be beneficial in both the prevention and treatment of COVID-19.  A regimen used commonly in hospitals early in the pandemic for treating severe patients was  Vitamin C 500mg twice a day, Quercetin 250mg twice a day, Vitamin D3 3000 IU once a day, Zinc 100 mg/day , and melatonin 10 mg at night.  These doses don’t have to be exact, and in my opinion, some of  the doses (Vitamin D, ZInc and melatonin) are likely too high.  However, if you are worried about getting sick from COVID, taking these vitamins might protect you.  Please note: if you are on blood thinners, Quercetin should be used with caution. All of these can be purchased individually over the counter and online.   There are also one or two combination pills that can be found online that have all of these vitamins in one pill,  except for melatonin, and they also contain a bunch of herbal supplements which may help as well.  In addition, there is a company that I work with that sells  high quality supplements, and has a product that has all of these vitamins in one pill, including melatonin, that you take two pills every evening.  Here is a link to the information about this product. Since I am a registered provider with them, if you decide to order, please use my Provider Referral Code (PRC)  220814 at check out (PRC Code not Discount Code), you will get my discount, which is $61 for a 90 day supply. You can share this code with anyone.   Preventing Long COVID from developing should you become infected. Long COVID, also known as long haul COVID or Post- Acute COVID, is a cluster of symptoms including pain, fatigue, and brain fog that seems to affect a minority of COVID infected patients.  While I don’t believe Long COVID is as common as reported in some studies and media outlets, it can not be ignored, and may be an important reason why people refuse to return to normal activities despite the decreased risk of serious COVID illness and death.  While the evidence is not nearly as strong for COVID prevention, based on many expert opinions and our understanding of what might cause Long COVID, there are vitamins, herbs, and supplements that you can take as soon as you get infected with COVID that can not only decrease your symptoms, but may substantially decrease your risk of developing Long COVID.   Vitamin Cocktail- the same combination listed above to prevent COVID, can also reduce symptoms and possibly help in preventing Long COVID.  Again, you can take these separately, or buy a combination online, either on Amazon or with a company I have worked with and trust (again please use my provider referral code or PRC 220814 to get my discount if you use this site).   Even more Vitamin C- for treatment and prevention of Long COVID, the dose of vitamin C should be higher,  at least 1g a day, and perhaps even higher.  Most of the vitamin cocktails and multivitamins only have 500mg, so you will need more.   Turmeric/Curcumin– Turmeric is a common spice which contains curcumin, which is known to have many anti-inflammatory properties, and may decrease symptoms as well as prevent the cascade of inflammatory steps that lead to Long COVID.  Dosing for illness is at least 500mg.  Please note: if you are on blood thinners, you should not take turmeric or curcumin.   N-Acetyl-Cysteine- N-acetyl cysteine (NAC) is a supplement form of cysteine. Cysteine is considered a semi-essential amino acid, and is found in most high protein foods, such as chicken, yogurt, cheese, eggs, and legumes. NAC replenishes the most powerful antioxidant in your body, glutathione. Oxidation is considered one of the key steps in developing Long COVID, and there is evidence that NAC may prevent the virus from binding to the receptor in our body which is critical to COVID causing damage.   NAC doses for COVID treatment range from 600mg to over 1g a day.   NAD+/nicotinamide riboside/nicotinamide mononucleotide- Nicotinamide adenine dinucleotide (NAD+)is a critical enzyme found in every cell in your body and has a critical role in your body’s ability to make and use energy. This is thought to be a major issue with Long COVID.  While nicotic acid is a precursor to NAD+ (and used to lower cholesterol) it has side effects, including flushing. Other precursors to boost NAD+ include nicotinamide riboside and nicotinamide mononucleotide which have no side effects.  There is evidence and current research looking at precursors of NAD+ to treat and prevent Long COVID.       As with all vitamins and supplements, these can be purchased in the pharmacy, in a vitamin shop like GNC, or online.  While some combination products (in addition to the Vitamin Cocktail I have previously mentioned) may be available, the dosing in combination pills is generally not high enough for these additional supplements, so you will likely need to take all of these separately, which I realize is a lot of pills and can add up to a lot of money.  Thus, I am not recommending these supplements for every patient who gets COVID, since most cases are mild and resolve without any medicine or vitamins.  However, if you are again fearful of becoming ill or contracting Long COVID, and still limiting your activity because of these concerns, you can buy these supplements in advance, and should you get infected, start them as soon as symptoms begin to prevent becoming sick or getting Long COVID.  I would recommend taking these supplements for at least  one month, and probably for at least three months/90 days to ensure  Long COVID doesn’t develop.  Because of high prices and concerns of quality, I have spent significant time looking for an online pharmacy that has all of these at reasonable prices.   Here is a link that has all four of these products at a steep discount.     Again, these supplements are meant to be taken at the onset of COVID infection  along with the aforementioned Vitamin Cocktail.  If you did not already purchase the combination product I previously mentioned or don’t already have something similar, you can add the following two products to the order from the link above. Just search the site and add to your cart before you check out: BioCap Immune™ and Melatonin.   I am hopeful that the above information about these concrete things you can do besides masking and vaccines (i.e. nose sprays, supplements) to prevent contracting COVID, and prevent Long COVID if you do get sick, will encourage even the most reluctant of you to get back to your normal lives. Not getting back to normal is unhealthy, for you and your spouse/ significant other.    I realize this is a lot of information, especially regarding the supplements, so if you have any questions or concerns, please don’t hesitate to reach out.  Author Matthew L. Mintz, MD, FACP

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