As more Americans become vaccinated and we look forward with hope, there is a group of people who can’t seem to fully recover from the virus. These COVID “long hauler” patients say that their illness continues to limit their day-to-day activities months after they recuperated from the initial infection. This long-term public health issue is the focus of this episode, hosted by Jonathan Fialkow, M.D., deputy medical director and chief of cardiology at Baptist Health’s Miami Cardiac & Vascular Institute with his guests:
Samer Fahmy, M.D., Chief Medical Officer at Baptist Health's Boca Raton Regional Hospital
David Mishkin, M.D., Emergency Medicine Specialist for Baptist Health
Madeline Camejo, Pharm.D., Chief Pharmacy Officer for Baptist Health
As more Americans become vaccinated and we look forward with hope, there is a group of people who can’t seem to fully recover from the virus. These COVID “long hauler” patients say that their illness continues to limit their day-to-day activities months after they recuperated from the initial infection. This long-term public health issue is the focus of this episode, hosted by Jonathan Fialkow, M.D., deputy medical director and chief of cardiology at Baptist Health’s Miami Cardiac & Vascular Institute with his guests:
Samer Fahmy, M.D., Chief Medical Officer at Baptist Health's Boca Raton Regional Hospital
David Mishkin, M.D., Emergency Medicine Specialist for Baptist Health
Madeline Camejo, Pharm.D., Chief Pharmacy Officer for Baptist Health
Announcer: At Baptist Health South Florida, it's our mission to care for you when you're injured or sick and help you stay healthy and fit. Welcome to the Baptist Health Talk Podcast, where our respected experts bring you timely practical health and wellness information to improve your family's quality of life.
Dr. Fialkow: Welcome, Baptist HealthTalk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Baptist Health's Miami Cardiac and Vascular institute, as well as chief of cardiology at Baptist Hospital and the chief population health officer at Baptist Health.
As more and more Americans become vaccinated and we look forward with more hope, there is a group of people who can’t seem to fully recover from the virus. These COVID “long hauler” patients say that their illness continues to limit their day-to-day activities months after they recuperated from the initial infection. It’s shaping up to be a major, long-term public health issue.
On a recent episode of Baptist Health’s Resource Live program, we discussed what we’ve learned about Post-COVID Syndrome. My guests were: Dr. Samer Fahmy, Chief Medical Officer at Boca Raton Regional Hospital, Dr. David Mishkin, Emergency Medicine Specialist for Baptist Health South Florida and Madeline Camejo, Chief Pharmacy Officer for Baptist Health.
Let’s listen in….
Dr. Fialkow: We'll start with a question to Sam, Dr. Fahmy. You know, we're over a year into this pandemic, we're still learning so much about the coronavirus on a daily, almost hourly basis. Broadly, what has the research told us that we didn't really know before about COVID-19?
Dr. Fahmy: Well, we have definitely learned a tremendous amount over the last year and a half or so of studying COVID. I mean, the amount of research that has gone into COVID-19 is greater than any other disease that we've known in our modern medicine past. It seems on a daily basis, new articles and new evidence is coming out. But we've learned quite a bit about the various areas that we've focused on. I mean, in terms of transmissibility, we've learned a bit more about how the virus gets transmitted one person to the next. We know that the most common transmissions happens within the immediate family unit. You transmit it to the ones that you're closest to. We know that masking is protective and we've learned specific types of masks that could be more protective, with double layers rather than single layered masks. We've also learned, you know, that the isolation and when somebody does get infected with COVID, how long do we need to keep them isolated in quarantine? Whether it's 10 days for milder illnesses or 21 days for severe illness from the day that they got infected. And after that, it doesn't make much sense to isolate folks because the risk of transmission is extremely low, but more than anything, we've learned so much about the treatment and how to take care of somebody once they got infected with COVID. We have medications now and drugs like monoclonal antibody therapy, those big words but just means that synthetic antibodies, that we can give people that are at higher risk of progressing to prevent that progression. Medications like Regeneron, Bamlanivimab, Etesevimab, those medications that we're able to administer to somebody before they get really sick, help prevent the progression. And if somebody does progress and get worse we have medications in the hospital like steroids, Remdesivir, Tocilizumab, lot of big names to remember, but ultimately, we have tools at our disposal today that we never had a year ago because of that research. Convalescent plasma being a part of that as well, we've known about it all along, but we've tailored really where and when to give convalescent plasma to give the best benefits. So research is still ongoing and there's still much more to learn, but tremendous amount has gone into the research over the last year and a half. And we're seeing the benefits of that now.
Dr. Fialkow: It really is remarkable. We think back a year about the resources we put into place to prevent transmissibility not just among the population, but among our healthcare workers, and the really lack of knowledge we had regarding the disease states in the acute phase, and while this is still a very serious disease and it's very transmissible and people have medical consequences, we're better able to deploy our resources where they're most needed. As you've mentioned, we have treatments for that acute phase. I'm gonna go to Madeline for a second. So we've had a lot of people now who've recovered from the virus in terms of positive tests and whatnot, but they still have symptoms. What are we learning about the population who even after they've gotten through that acute phase, continue to have symptoms? What are the symptoms that we're seeing? And can you give us any kind of information regarding the trends that we expect?
Dr. Camejo: So, you know, much is still unknown about how COVID-19 will affect people over time but there's research that is still being happening now. And recent studies show that anywhere between 10 to 30% of COVID patients experience prolonged heart, lung and sometimes neurological issues for a period of anywhere between two to 10 months. And what research is finding is that a lot of this is associated with how the virus triggers a massive inflammatory response through your body. And this inflammation is what may be causing damage to your heart, your lung or your brain. And if you have an inflamed heart, that's why you would have these cardiovascular symptoms like chest pain, heart palpitations, you know, which is a fast and pounding heartbeat or shortness of breath, extreme fatigue. Symptoms that affect the brain would be experience of brain fog, you can't really think, you have an inability to concentrate, difficulty sleeping at night or sometimes headaches. And if so, if you're out there you've had COVID and you still experience these things, I think it's really important to talk to your doctor so that you can come in and have options for managing your treatment. But there are clinics now that are starting to set up across the country to really study this and figure out what they can do for some of these patients.
Dr. Fialkow: I mean, this virus we didn't even know what existed before a year and a half ago. So we can't tell people what it's like to have had COVID two years later or three years later, we're still learning that. Madeline, are we seeing a lot of these longer term effects only in the people who were severely ill, hospitalized, or are we seeing it in people who might've had a milder case?
Dr. Camejo:- No, they're actually seeing people who have mild effects, they just can't seem to shake off some of their symptoms. So it's not just about the folks who were intubated or were in the hospital. It's really has been people at home who never even made it to the hospital still experience some of these.
Dr. Fialkow: Are we seeing it in some of the young people or it's only the older people who are getting this?
Dr. Camejo: It depends. It's a varying of age but I've actually talked to a few folks in their thirties and twenties who still are not experiencing like they are back. A lot of them are really experiencing that brain fog situation, where they're having a hard time concentrating at work or at home
Dr. Fialkow: I've seen it as well. And I think the purpose of these types of conversations are not to frighten people, far from it, but to inform and that perception of the young people of, well, if I get it, it's no big deal. You know, you don't want to get COVID. Even if you think it's no big deal. We are seeing these long-term effects in people and we still don't know how long they'll last or what the consequences are. David, people get tested for COVID, they're positive, the test becomes negative, where are you seeing these patients who might have some of these longer term effects? Madeline alluded to, you know, cardiovascular effects and whatnot, are you seeing these symptoms? What are the more common symptoms you're seeing in the patients who are now past that acute phase maybe been tested negative, had the virus, that are having these longer term effects?
Dr. Mishkin: You know, interestingly, the vast majority of these long haulers will actually test negative for the virus and many will experience a symptom, as Madeline mentioned.
Dr. Fialkow: David, I'm sorry. Initially they were negative for the virus or?
Dr. Mishkin: No. After they have the virus they'll test negative, but have these sort of persistent long haulers symptoms that we described, that we're describing. Many will experience a symptom but over a third will experience multiple symptoms. And by far, what we're seeing the most common is really this debilitating fatigue. In addition to that, lingering cough, shortness of breath, especially worse with certain activities and other things like mentioned, body aches, joint pain, difficulty sleeping, headaches, but what also is very interesting is just, you know, brain fog that we've mentioned earlier. And this is that feeling of this sort of sluggishness, feeling fuzzy, not as sharp and things such as even writing an email, paying a bill, will just become more difficult for these patients than they were prior to having this virus.
Dr. Fialkow: And we're actually seeing that whether it be in our medical clinics or our doctor's offices or with our telemed services, we have, you're personally seeing that and you're personally seeing those experiences with people that you're taking care of.
Dr. Mishkin: Yeah, yeah. We are. And specifically, then as I mentioned earlier, that sort of debilitating fatigue is a very common symptom for these patients because we know that they did have the virus, you know, they got through the worst course of it, a lot of them, you know, were either hospitalized or as mentioned some of the younger patients we're not but they're having that lingering fatigue, you know, sometimes for up to one to three months after they've actually tested negative for the virus.
Dr. Fialkow: We'll talk about the vaccines specifically in a few minutes but Sam, there's been some reports that some of these long haulers or these you know, chronic COVID symptoms, when the people get vaccinated, they feel a little better. Is there any validity to that?
Dr. Fahmy: No, it's an interesting phenomenon and it was somewhat unexpected. I don't know if us as a medical community expected the degree that it was helping some folks. Now it's been reported, in the Journal of the American Medical Association report up to 30% of people who had these long hauler symptoms, these long COVID symptoms, improved after vaccination. And, you know, the jury is still out on why or why that would happen. Now there's still a very small percentage that may get worse after the vaccination. Those were detected as well but there's a couple of theories out there. One of the theories is maybe some of these folks that have longer symptoms have remnant virus, that's still dormant or, you know, more lower level sort of sleeping virus in their body, that's causing them disturbance and when you stimulate the immune system by getting the vaccine, it gives it enough power to be able to attack that dormant, remnant virus that's still in their system. There's other theories out there that it may stimulate a different portion of your immune system that's more active and suppresses another part of your immune system that may be causing the symptoms. The bottom line is we still don't know why some people get better, but we definitely know that some people report getting improvement. So, it's just more reason to get vaccinated even after you had the COVID infection. It's proven that it's harmless to get vaccinated after COVID infection. The CDC recommends that just wait, if you've been infected with COVID, wait till you're out of isolation, whether it's 10 days or 21 days, depending on the severity of your illness. You're eligible to get the vaccine, although a lot of our infectious disease specialists in the area say you can wait up to 90 days because you have already antibodies and they may be protective for a longer period in time but whatever period you decide to wait, it's definitely beneficial that you get vaccinated even after you've been infected and it may help prevent some of these long COVID symptoms.
Dr. Fialkow: I mean, for me, and I'm sure for you guys as well, the compressed timeline of discovering this virus a year and a half ago, you know, getting a vaccine for it, a safe vaccine, in such a short amount of time but even think of it in terms of we didn't know there was a COVID long haul cause people didn't have COVID and we couldn't follow them for awhile. And now we're already observing things that can actually make them better like vaccinations. So again, more to learn about COVID and its consequences and I'm sure more we'll be able to do to keep people healthy after COVID.
Dr. Fialkow: Madeline, vaccines. You know, 800 pound gorilla, you know, in terms of, you know, our society and getting through COVID as well as an incredibly valuable weapon. Over 30 million Americans have been fully vaccinated, two doses of the two dose vaccine, single dose numbers are growing daily and many people with their first dose waiting for the second dose. It's about 10% of the population fully vaccinated. What's the difference between the three vaccines that are available today and should we be questioning the effectiveness of all of them or individually, the vaccines?
Dr. Camejo: So the three vaccines we know that have been granted emergency use authorization is Pfizer, Moderna and Johnson and Johnson. And the Pfizer and Moderna vaccines are made using messenger RNA, which is a piece of genetic code that tells our cells to safely create proteins similar to those of the Corona virus, and once those proteins are made is when our immune systems then creates the antibodies. And the thing about the mRNA vaccine is that the effectiveness is around up to 95% of protection from Corona, which is really good. And the difference is that both the Pfizer and Moderna are a vaccine series of two shots, where Pfizer is 21 days apart and Moderna's 28 days apart. J and J is what we call a vector vaccine. And this type of vaccine, the genetic material from COVID is kind of inserted into a weak adeno virus, kind of like a Trojan horse. And it goes through your body and it serves as a delivery system into your cells and that's what gives your cells instruction to then create the protein, and it activates your immune system to breed the antibodies. Now, the effectiveness of the vaccine for J and J in the United States is around 72%. It's about a one-shot dose. And at the end of the day, all these vaccines offer really good protection against severe COVID disease, hospitalization, death. So, you shouldn't wait to get... You shouldn't wait, you should get any vaccine that's offered in your area because at least it will prevent you from severe, severe COVID and landing in any one of our hospitals.
Dr. Fialkow: That's a great point I think should be emphasized: vaccinated people, even if they get COVID, and you'll always hear about a case, and no one is saying that by being vaccinated you'll never get COVID, you're not gonna get severely ill. You're not gonna die. So even if a vaccine fails in the sense that someone still may get COVID, which is unlikely, it's gonna be a much milder case. You mentioned that the 72% efficacy, can you unpack that a little bit? Does that mean if someone gets the J and J vaccine they have a 28% chance of getting COVID. Can you explain that number a little bit regarding the efficacy? I think that's something that I see gets misunderstood quite often.
Dr. Camejo: No, it doesn't. All the vaccines really do create that protection from you to landing. It's just that against variants and other mutations that we're now having in the United States, the effectiveness really is just about how it protects against certain strains of COVID. And so doesn't mean that it will not protect you. It's really important, all of them will come protect you against really landing you severely sick and having all of the horrific side effects of COVID later on as well.
Dr. Fialkow: When people ask you, should I wait to get this vaccine, cause I can get this one today, what do you tell them?
Dr. Camejo: No, get whatever you can get, as soon as possible.
Dr. Fialkow: A leading question I think everyone...
Dr. Camejo: To me, is the longer you go unvaccinated, the higher risk you are at getting COVID and you know, these strains continue to mutate out there and we just don't know, right now you know, one strain can be worse than the other. And it's just really important. At least the vaccine will protect you from really getting sick and landing in the hospital.
Dr. Fahmy: And Jonathan, if I may?
Dr. Fialkow: Please.
Dr. Fahmy: As Madeline mentioned, something really important is that getting vaccinated is important but getting everybody vaccinated quickly, is just as important. The longer we have this virus out there circulating and spreading, and these hotspots around the globe forming, the more variants we'll get and the less the vaccines will be effective so the faster we're able to get everybody vaccinated quickly around the globe, not just within the United States, the faster we'll get ahold of this and get the virus under control.
Dr. Fialkow: That's a great point. And that's why I actually tell my patients while it's important for them to get vaccinated for their own safety and health, for me, it doesn't matter if it's a 20 year old or a 60 year old or a 90 year old, I'm protected equally and that the public health is protected equally by the more people that get vaccinated and as quickly as they get vaccinated for the reasons you described. It's a great point with that as well and for our viewers, please, not only yourselves but get people you know who might be reluctant to reluctant to get vaccinated as quickly as they can.
Dr. Camejo: Yeah. And the other piece to this, Jonathan, too, is the fact that, I have a lot of people say, well, I already got COVID, I don't need to get vaccinated. And the importance of that is you need to get vaccinated cause you're gonna get COVID again. There's been a lot of people who have gotten COVID several times over.
Dr. Fialkow: Right, the original thought was you get COVID, you're immune and we're not finding that it does not protect you, so that should not be something that comes into your decision making. David, something that, you know that speaks to your passion and your expertise. You know, the pandemic's changed the way we do everything which includes how we go to doctors or engage with our healthcare providers. Patients can now visit their doctors through a screen, virtually, phones, apps, on an iPad or a tablet or computers. You know, is telemedicine here to stay?
Dr. Mishkin: You know, to answer that question best, I really feel that we've reached this inflection point where the attitudes of telemedicine have really started to change. For example, a large national telehealth provider surveyed 600 physicians and 2000 consumers and what they learned is that prior to COVID-19, maybe only about 8% of patients and maybe 22% of doctors in this survey, have ever experienced a telehealth visit. Fast forward a year later and that number has increased threefold up to, you know, well over 20 to 25% of patients. And, you know, getting up to now 80% of doctors who have experienced a telehealth visit. And what's interesting is that over 60% of these patients had their first ever telehealth visit during the pandemic. And well over 90% of physicians are starting to now say that their belief that this modality is both safe and effective to continue using telehealth to practice medicine and treat their patients. So to really answer your question best, I think telemedicine is here to stay and I think it has a bright future ahead for it to be able to take care of patients in a more, you know, accessible and cost effective manner.
Dr. Fialkow: - It might seem obvious, but if you could articulate what about the COVID pandemic provided for or was a catalyst towards the telemedicine adoption?
Dr. Mishkin: I think first and foremost is that there was just a general unfamiliarity with this type of care. And one of the reasons why telehealth was such a challenging thing to grow prior to the pandemic is because there was so much regulation behind it about you know, giving the physicians access to do it, the type of things we were allowed to treat, the type of patients we were allowed to see and even where those patients were located. But when we experienced the beginning of this pandemic and you know, president declared a state of emergency, what this allowed us as providers to do is to lift up a lot of those regulations, use different types of electronic platforms to communicate with our patients, it gave us the ability to really treat patients for more and different types of things, and then that was really a catalyst for us to really let this continue to grow. In addition, we learned very early on that there was a lot of unknown about this virus. Was it safe to leave your home? The patients still had medical needs, they needed to connect with their doctors and we found that this was the best way to do it. Moving forward, our future is bright because although we're having patients to start come back into our offices, into our practices to treat them, now we're learning how to do this in what we call a hybrid approach. And that approach is saying, there are some things that are great for telehealth and there are some things that are great for, you know, bringing our patients in person. And we don't really want this to be mutually exclusive but we want to hybrid that relationship, so we can kind of do it together and provide the best care for our patients.
Dr. Fialkow: I remember we looked at in the early stages and it's still prevalent, but when we were short in supply of gowns and masks and gloves for health care providers we always said the best PPE, the best personal protective equipment, was a telemed visit. You don't have to get gowned up to be exposed for it and I think that was a big component as well of the safety of the people staying home and getting the medical care which is gonna continue. You know, as a cardiovascular provider we're certainly using telemed and even those low acuity visits, going over test results, changing medications, certainly appropriate, but there is a flip side, David. So where would you say we shouldn't use telemed? Or what are the kinds of symptoms or things when we want people to say, go to the emergency room or call 911, it's safe to say we don't want every medical complaint to be through a telemed visit. So what do you recommend when you go out and promote the telemedicine services?
Dr. Mishkin: A very important question. You know, our goal is to deliver the highest quality and the safest care. So, you know, patients that are experiencing things like chest pain, stroke-like symptoms, I mean those are medical emergencies. Those are things that, you know, you need to immediately call 911. And I think what we're learning, even from the telehealth experience of is that, you know, that hasn't really changed much about the type of things that patients are, you know, delaying care for that are really true emergencies where they need to, you know, rush to emergency centers to get timely treatment. However, what we've always learned in healthcare is that, a lot of the really important medical illnesses get delayed and those delays can lead to bigger problems down the road. And so with telehealth, what we're really giving patients is our access. And by giving us our access to have these virtual visits, in a very cost effective and timely manner for a patient, we can kind of handle these problems earlier. And what it's really doing is that it's leading to a lot of less down stream complications for these patients. In addition, a lot of times patients are uninformed and they want to know when they have a medical problem, what do I do? What do I do in the middle of the night when I have a symptom? Do I need to rush into a hospital? Maybe I can call my primary care doctor in the morning. We are accessible and we're available to talk to you about those symptoms and give you the best advice at the time you're experiencing them. So in many ways, despite the fact that we don't want patients to delay timely care for telehealth, that could potentially impact their life, we do want to offer telehealth as a solution to get in front of a healthcare provider earlier to potentially not delay something that could be more dangerous down in the road. And so that's really our benefit.
Dr. Fialkow: I just want to go to each of you quickly and I think it's really important, we've known each other for a while, we've had these types of forums together for awhile, what's this year meant to you? I'll start with you Madeline, what has this year and this COVID pandemic meant to you?
Dr. Camejo: For me, it's been a long haul but very gratifying to be able to help people during this pandemic, especially for pharmacists. This is really a once in a lifetime event that we haven't experienced and I'm very grateful to work for an organization that has really done an amazing job in trying to help and treat all our patients in South Florida.
Dr. Fialkow: It may not be recognized, but you and your team clearly are the tip of the sphere for all of our treatment and our vaccination efforts and we wouldn't be getting through this without you guys. Sam, what's this meant for you in your role and in your experiences.
Dr. Fahmy: I think over the last year, we've learned to lean on each other as a healthcare community and as a team within hospitals and within doctor's offices and even further, in community with the health department, with national guidance from the CDC and FDA, it's really connected us as healthcare providers to be able to provide the best care and be able to lean on each other in times of great anxiety and great fear when there's plenty of unknown. And when we're still learning more about a new disease, it just really brought teams together and brought us to the point where we're all working together for the benefit of patients and making sure that the patients are getting the best care possible within our institution. I think it takes a crisis like that to show your true colors. And I think as a community, we all stepped up and I think that showed our colors and that we will put ourselves at risk, we will maybe even take some of that risk back to our homes and our families, to be able to provide that best care for people that need it. So it was a great learning experience, but I think it's brought us, as a hospital as a community, much closer together.
Dr. Fialkow: We're certainly grateful for you and your leadership as well. David, 15 seconds, what does it mean for you?
Dr. Mishkin: I think just, you know as emergency physician, what I've learned, what I continue to learn, is that we must continue to work together to solve our most complex problems. We have to take care of ourselves to take care of you know, others better. And even in our darkest days, we rely on our knowledge and our innovation and really our perseverance to get through this and that's what I've learned through this past year.
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