Insights about COVID, Long COVID & More

Show Notes

Where do things stand now in terms of COVID, Long – and even Medium COVID?  What have we learned after the past three years, and what should we, going forward?  On the latest Healthy Conversations episode, Dr. Kirsten Anderson, senior medical director for New England for Aetna and CVS Health, shares insights with Daniel, and tells why she feels the role of public health is more important than ever before now.

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Dr. Kirsten Anderson:
Personally, as a clinician, it just breaks my heart that people have experienced long COVID, and really makes me want to get everybody vaccinated even more so because that has been shown some promise in decreasing the long COVID effects.

Dr. Daniel Kraft:
Welcome to Healthy Conversations. I'm Dr. Daniel Kraft, and today I'm in Healthy Conversations with Dr. Kirsten Anderson. She's a senior medical director for New England for Aetna and CVS Health. Welcome to Healthy Conversations, Dr. Anderson. Like me, you're trained in internal medicine, and you've had a really fascinating career to date, blending internal medicine, epidemiology, and now your positions with Aetna and CVS.

Dr. Kirsten Anderson:
Yep. I trained in internal medicine, but I always had an interest in public health, and specifically epidemiology. And so I really think that working at Aetna CVS Health is a way of reaching, educating, a large population. You have four million people a day visiting our pharmacies, a couple hundred thousand employees. All of those people can be reached with the messaging that we can bring to them clinically to keep them healthy. Working in a place like Aetna CVS Health is a really good way to do public health, to improve the health of a population.

Dr. Daniel Kraft:
Right, because blending the population that comes through your pharmacies and through your sort of peer network, you get a tremendous amount of data. What kind of public health data can you parse some insights, just from maybe who buys what in a pharmacy, or all the way to what billing codes are being utilized?

Dr. Kirsten Anderson:
To your point, we can figure out how many people saw the doctor for COVID, how many people saw the doctor for a fever, or how many people saw the doctor for long COVID. Marry that with the data from CVS Health, which talks about how many people got a vaccine. How many people went to the pharmacy, but then didn't get a vaccine? It affords us the ability to really reach out to people and to target them for specific education.

Dr. Daniel Kraft:
Now we're almost overwhelmed with data, but often, the challenge is really making the meaning of that, and certainly in the setting of the pandemic, things moved a bit more quickly.

Dr. Kirsten Anderson:
Yeah. If you think about the messaging that came out from this pandemic, and all of the contradictory things that people heard, and all of the changing advice, the concept that we held fast to was make it simple. Deliver a simple message to people so they understand what to do. If it's too complicated, people will turn off and they will stop listening.

Dr. Daniel Kraft:
Kind of like the drug packaging inserts that you get at the pharmacy aren't particularly well-designed for understanding. I know you've seen a lot of insights and impact of long COVID, like chronic fatigue type symptoms, respiratory issues, brain fog that can persist for months, or some folks are still suffering from it two years after their initial infection. But recent studies have really shown a greater risk emergence for this sort of middle phase for the majority of folks who are vaccinated and hopefully boosted. And that phase can often last for 12 weeks after the initial sickness and fade. Some have begun to call it quote, unquote, medium COVID. Is it really a thing or just society's need to label everything as related to the pandemic?

Dr. Kirsten Anderson:
Medium COVID I think is just an extension of the initial acute phase of COVID. So you've gotten a cold and you just can't shake it, and it takes a couple weeks, or maybe it takes a month. And you have a lingering cough. That's exactly what medium COVID ... That's how I'd explain it. What I want to point out though is that if you're vaccinated, you have less of a chance of getting either medium or long COVID, so it's important for everyone to get vaccinated.

Dr. Daniel Kraft:
I think you and your team could provide some lessons to the CDC, which I argue in some ways didn't message things very well. You promised us vaccines would mean we wouldn't get COVID. Now it's more that it will ameliorate it and make the short and long-term complications much less likely. And the long COVID implications are sometimes much more scary than the acute.

Dr. Kirsten Anderson:
We can think about where we've been and where we're going. Where we've been is a pandemic that killed a million people just in the United States. And where we're going is to a place where we have 300 to 400 people die a day from COVID, and 150,000 people a year. So how did we get from there to here? Vaccines have gotten us to the point where we can have a more normal life than we had during the pandemic, and that is a good message we can communicate to people.

Dr. Daniel Kraft:
I totally agree, though we still see a shockingly high number of Americans who are not vaccinated, or sometimes feel like they think the pandemic's in the rear view mirror, and we're entering as we speak the fall and winter of 2022, where new variants are rising, and a relatively small percentage of folks have gotten the new bivalent booster. Have you learned ways to kind of engage not necessarily the anti-vaxers, but the folks who may be on the fence?

Dr. Kirsten Anderson:
I think that there's a lot of acceptance around the flu vaccine. One of the important things is convenience, so people walk into the pharmacy to pick up a tube of toothpaste, and then they get a flu vaccine. We're making it the same kind of convenient for the COVID vaccine, and we're giving the COVID vaccine at the same time as the flu vaccines.

Dr. Daniel Kraft:
I did that myself. I had the CVS app reminded me I was due for my flu booster. I got scheduled and went in. I got the mouthwash, not the toothpaste this time. But it's going to have to become part of our hopefully public health hygiene.

Dr. Kirsten Anderson:
That's right.

Dr. Daniel Kraft:
Let's circle back a bit to this issue of medium to long COVID. I guess I was fortunate, unfortunate to get COVID right before the vaccine came out. And I had it one other time after vaccine, but it was much more mild. There are some commonalities to the issues of what's now being termed long COVID. A study in Sweden found a chance of a pulmonary embolism was 30 times higher in the first month after being COVID positive. But that kind of went down to two times the risk after 60 days. So now that we've seen that there's a lot of danger in the initial weeks, not months after COVID, how do you see that impact our need for treatment?

Dr. Kirsten Anderson:
Right. So those are all really interesting studies and underlies the complexity of the virus that causes COVID. It really has a lot of different effects across all systems in your body. We've learned so much in this pandemic. What are the medications if you're unfortunate enough to be in the hospital that really work? What are the medications that decrease your side effects, that decrease your chance of having blood clots and pulmonary embolism? We also have outpatient treatments, so we have Paxlovid, and that can be prescribed by the pharmacist to help people who are at risk of becoming severely ill. It's a little bit of a hard medication to take because it has some side effects, but it's extremely effective in decreasing the symptoms and decreasing the length of infection, so you have a good way of protecting yourself if you're very vulnerable.

Dr. Daniel Kraft:
There's always shifting definitions of who's vulnerable, so many factors, from genetics, to other comorbidities you might have, that have different paradigms. As you said, a pharmacist can prescribe Paxlovid. Will we be in an era soon where you've tested positive, your app knows you've tested positive because you have a digitally connected diagnostic informs your clinician, your public health system, but also, routes the Paxlovid prescription from your pharmacy and it arrives by drone or by delivery service at your door, particularly in those first couple of days when it's most effective?

Dr. Kirsten Anderson:
We're far off from that, especially the drone part delivering you Paxlovid. But I think that one of the things that we really strive to do is the test to treat. Here's the way this works, so you've gone to CVS. You have had a test, it comes back positive. And within the medical record that we have at CVS, we can see that you don't have any contraindications, then that medication can be prescribed at the time, so right then. That's why it's important to have this interoperability so that we can get if off the shelf and into your hand.

Dr. Daniel Kraft:
I heard a report recently that we know about some of the social disparities from the pandemic, but that let's say in the African American population, a much lower fraction who was eligible for Paxlovid ended up receiving it. Are there ways you've seen this sort of enhance the understanding that these antivirals can be particularly helpful?

Dr. Kirsten Anderson:
So during the pandemic, we really partnered with all kinds of community organizations to get the word out about testing, about vaccination. We need to continue those partnerships and continue to get the word out to communities that may not traditionally have had a lot of access to health care.

Dr. Daniel Kraft:
What do we need to do to better educate the general public about health literacy? And certainly, that ties into the info-demic that we've seen in terms of folks who aren't just anti science, but just end up on the wrong side of the equation about understanding how medicine and science evolves.

Dr. Kirsten Anderson:
I think it's a very pertinent question. You hear people who say, "Well, the CDC told us in the beginning we didn't need to wear masks. And so why do we trust them now?" I think we need to make it clear that science evolves. We get new data points. We understand more about diseases as time goes on. And there will be obvious missteps along the way when you're dealing with something that is moving as rapidly as a respiratory pandemic. It was not wishy-washy behavior. It was in fact being able to make decisions based on the information that you have today. That information may change tomorrow, as the medical evidence develops. And that is a message that we know now, we didn't know at the beginning of this pandemic. It's because we haven't had a pandemic in a very long time, so people are very used to having absolute answers about how to address diseases. When a new pandemic, there are no absolute answers. Bear with the scientists and bear with the public health experts because they're learning just as everybody else is.

Dr. Daniel Kraft:
It was called a novel virus for a reason. And we certainly did accelerate knowledge about creating [inaudible 00:10:22] vaccines, virtual collaborations, crowd sourcing, even the long COVID population. What are some lessons and things that we failed to learn from the pandemic side?

Dr. Kirsten Anderson:
So, and I must say, I have to reiterate this to my kids all the time, this is not necessarily about you. It's about you and your neighbors. But they say, "Mom, if I get COVID, I'll be fine." And I say to them, "It's not about you. It's about your friends' grandparents, your friends' friends who are immunocompromised and you don't know about it, your friend's parent who has a kidney transplant." People did come to understand in this pandemic that it's a respiratory illness that can be transmitted from person to person, but they didn't clearly see the chains of transmission and how important it is to break those chains.

Dr. Daniel Kraft:
100%. So speaking again back on the long COVID element, but for clinicians. I think most of us are familiar with the traditional now long COVID symptoms, severe fatigue, sometimes quote, unquote, brain fog, respiratory issues that are worse than the sort of medium to post infectious phase. At least a Swedish and UK study found that the after effects decreased from 83% in the four to 12 weeks after illness, and the US has similar results. But that sort of trajectory isn't often homogenous. How would you say we better educate health professionals of all sorts to understand they can recognize when folks are not on the recovery path, and what research and potential therapies might be available to them?

Dr. Kirsten Anderson:
We've had questions like this along the way, and there are some research centers scattered across the United States, probably in every major city, where they're collecting information about long COVID. When people have long COVID, they tend to first see their primary care physicians. It's an issue of educating primary care physicians and certain specialists around being on the lookout for these kinds of symptoms, so that people with long COVID can be counted and included in these studies that then will enable us to have a better understanding of the natural history of this disease.

Dr. Daniel Kraft:
And I would imagine with the Aetna data and insights from billing codes, to also pharmacy records, you might start to identify who looks like they really are on the debilitating side of long COVID and identify who might qualify for a clinical trial.

Dr. Kirsten Anderson:
There's a diagnosis code that a clinician can use for long COVID. Some clinicians use that, some of them don't. I know that clinicians don't like to do coding. They think it's just an administrative thing that doesn't really pertain to them. So one of the educational items that I would say would apply to both primary care physicians and certain specialists, if you think a patient has long COVID, put it on the claim because then it gets to us, and then we can find those patients and do what you're suggesting, which is identify people who might be at higher risk, or identify people who could benefit from an outreach.

Dr. Daniel Kraft:
I would argue that the future is coming a bit faster than we might think. A Stanford colleague, Mike Snyder, and his lab published about a year ago that, yes, the Apple Watch could pick up who has COVID one or two days before they're symptomatic, which means they might get tested earlier, won't infect others. There's also [inaudible 00:13:44] out of San Diego, the tech study that would find folks who have the flu. And ideally, that taps into a more holistic crowd-sourced set of knowledge that can drive epidemiologic and public health measures.

Dr. Kirsten Anderson:
Right.

Dr. Daniel Kraft:
A recent Brookings Institute study found that about 1.8 to four or so million full-time equivalents individual could be out of work due to long COVID, so it has huge impacts to everything from supply chain, labor shortages in health care and beyond.

Dr. Kirsten Anderson:
We have to treat long COVID like we treat any other disabling medical condition. It has a diagnosis. It is recognized. I've heard it described as sort of this wave of disability, this wave coming of people who are unable to work because of long COVID. It's a different epidemic and we need to address it with the policies that we have for leave and disability at every employer, that enables people to manage that chronic illness. Personally, as a clinician, it just breaks my heart that people have experienced long COVID, and really makes me want to get everybody vaccinated even more so because that has been shown some promise in decreasing long COVID effects.

Dr. Daniel Kraft:
And part of the challenge with long COVID, it's a syndrome of diseases or heterogeneous groups, some are pulmonary, some might be neurologic.

Dr. Kirsten Anderson:
Right.

Dr. Daniel Kraft:
Are you aware of any panel of, let's say lab tests, that could help make the quote, unquote, long COVID diagnosis?

Dr. Kirsten Anderson:
So when people come in with symptoms, we just check them for normal anemia, thyroid problems, things like that. So there is no one panel, but I think it's important to document and code so we can understand the magnitude of this problem.

Dr. Daniel Kraft:
I recently came across a paper where researchers had analyzed data from many folks in the long COVID diagnosis realm, and they'd found an increased level of about 12 proteins involved in it, oxidative stress, metabolic re-programing, cell adhesion, which sort of facilitate cellular actions compared to those who were negative for the longer impact. So I think we'll start to maybe be able to look at our proteome and metabolome and find more folks at risk. Even the National Institutes of Health has this new recover initiative, where you can sign up at recovercovid.org, and share your COVID experience, whether it's short, medium, or long, or even if you've never been infected, to help understand that broader picture.
And there's also another crowd-source platform for health information called Stuff That Works, stuffthatworks.health. I think several hundred thousand people have shared what's worked and not worked for their short, medium, and long COVID. So I think we'll learn a lot from the power of the crowd.

Dr. Kirsten Anderson:
But I'd like to caution that just a little bit. The power of the crowd is a good thing, but it needs to be confirmed with large scale clinical trials.

Dr. Daniel Kraft:
Sure. It's more a matter of maybe getting a more heterogeneous group, not just the usual suspects, into our databases, but we're all familiar with the Framingham trial driven by I think mostly Caucasian nurses in Western Massachusetts, which still drives a lot of our cardiovascular, who gets the statin. So a large prospective study, a [inaudible 00:16:46] review of long COVID found that women are more likely than men to experience both the physical and psychological symptoms, including autoimmune, rheumatic conditions, fatigue, depression. Do you have any thoughts about this sort of finding and why some people might be more susceptible? And how can we help medical professionals address the disparities in who gets diagnosed and what might best help them?

Dr. Kirsten Anderson:
So the way we phrase it here is that women are the chief medical officers of their families. What I suspect might be happening is that women are in tune to their health, to the health of their families, and they are more likely to seek medical care. And I'm not sure whether women are more susceptible, but they may be more aware. If we really do think that there's true disparities around women getting long COVID more than men, then again, it's something that we need to make our health care professionals aware of.

Dr. Daniel Kraft:
There's been examples in the last few months where an Australian company called ResApp was acquired by Pfizer, they developed the ability to listen to your voice, or your breath, or your cough, and determine: Is that a cold, croup, from RSV, as we have right now, or COVID?

Dr. Kirsten Anderson:
Yeah. That's pretty neat.

Dr. Daniel Kraft:
Have you seen anything else interesting in that space?

Dr. Kirsten Anderson:
What I think is interesting in that space is what we're doing right now with virtual, really trying to encourage people to connect with a clinician virtually. I'd like to encourage people to try to do that. So all over the country, we just do not have enough doctors and nurses and practitioners to see everybody, and so using digital care, using virtual care, to take care of some of these things, I think solves a big problem.
Let's say you go to your primary care doctor for a visit. You can't get in to see that doctor for another year. I mean, that's the case with me. I can't see my primary care physician. I see him once a year. Okay, so what do I do in the interim? I can talk to him virtually. I think we need to think out of the box. We need to make sure that people have access, that they can seek different kinds of practitioners in proportion to the severity of their illness.

Dr. Daniel Kraft:
And COVID's certainly been an accelerant for let's say virtual care, digital health in general. Have you seen some new solutions emerge? And what might you think you'd ask the powers that be to help generate next?

Dr. Kirsten Anderson:
Well, I'd ask the powers that be to fund public health. So if you think about this from a historical perspective, we had most of the diseases in our country and our world, they were due to public health problems like proper sewage disposal, lack of clean water, diseases that we got from burning coal, anemia because of nutritional issues. So we had this constellation of issues that made us sick and that were fixed by public health. And we don't remember that. In this country, we spent a long time not thinking about public health, and then we get a pandemic of this magnitude and we don't know what to do. And because our public health infrastructure has been so decimated, it's a shell of what it could be. And so if I would ask for something in the future, I would ask for funding for public health. So the next time someone says, "Call your public health department," it's not something that operates from 9:00 to 5:00 Monday through Friday. There would actually be people there who could help you. And that's what I think we need.
We also need more trust in public health. Many public health officials have resigned. They've been threatened. And so shoring up trust in the public health system and funding that, that's going to be critical for the next time we encounter one of these. You need that leadership. You need leadership in public health to be able to say, "A, you can trust us. B, we're doing this for you."

Dr. Daniel Kraft:
How do we trust that trust issue? Some see Dr. Fauci as a hero, as I do, and others are demonizing him. We teach sex ed in high school. Should we be teaching public health and epidemiology and how to understand clinical trials and vaccines, and help people realize that most of our longevity went from 40 something years of average life expectancy, 100 so years ago, to 70 plus. It's all mostly driven by public health measures, not by fancy anti-cancer gene therapies.

Dr. Kirsten Anderson:
Yeah. Teaching it in school would be a great idea.

Dr. Daniel Kraft:
I recently [inaudible 00:21:07] a talk from Michael Milken, of all people, about a little bit of a history of public health, going back to the polio epidemic, and when the Salk vaccine came around, there were some similar, let's say issues of distrust, and folks not rushing to get it for them or their kids. And it turned out when they found the right public figure to take it, it changed the perspective. That was Elvis Presley. So who's the Elvis Presley of 2022, 2023 who might help move the needle from some of the folks who are public health or vaccine resistant?

Dr. Kirsten Anderson:
That's a good question. We've had all kinds of people try to be the Elvis Presley. Each generation has their own Elvis Presley, so I'm not sure that just one figurehead would do it in this age of social media. One of the things that we find drives patient behavior is fear and anxiety. And one of the things that I was very honored to do over the past several years this pandemic was to be a voice of sort of calm within the organization, and also for our customers, is to be able to say, "Here's what we know. Here's what we're going to expect. And here's what you could do." And that serves to reduce anxiety.
It reduces people's anxiety about the future. It reduces their anxiety that leads to unnecessary ER visits. Reducing that anxiety is really important in keeping a calm and healthy workplace. And so I think that it's important that we not only have public health messages from the CDC, but every place that you can get a message, at your pharmacy, at your employee, is the right place to say, "Here's what we know. Here's what we should do about it. And here's what you can do to protect yourself."

Dr. Daniel Kraft:
Well, Dr. Kirsten Anderson, thank you so much for joining us today on Healthy Conversations.

Dr. Kirsten Anderson:
Thank you, Dr. Kraft.

Dr. Daniel Kraft:
And you can find other Healthy Conversations at healthyconversations.health.