Kind: captions
Language: en
[Intro]: Welcome to 'COVID's Lasting
Impact: Caring for Immigrant, Migrant,
and Asylee Patients', a 10-episode mini-series
within Migrant Clinician Network's 'On The Move'
podcast, a podcast dedicated to providers
who work with vulnerable populations,
specifically migrant populations. In this
mini-series MCN provides clinical teams,
including community health care workers and
Primary Care clinicians, with up-to-date
information, expert guidance, resources,
and relatable case stories for identifying,
treating, and managing COVID and long covid
among US-based immigrant, migrant, asylee,
and limited English proficient patients in
the outpatient setting. MCN is a national
non-profit with extensive experience
providing timely, practical solutions,
at the intersection of vulnerability, migration,
and health. Each episode provides clinicians with
impactful tools and information for improving the
quality of COVID care for vulnerable populations.
if you want to hear future conversations on the
topic of Health Justice be sure to subscribe
to the 'On the Move' podcast. For resources
mentioned in today's podcast be sure to click
on the link in our episode notes to go to our
podcast page at migrantclination.org/podcasts.
[Music]
[Liebman]: Welcome back everyone to another
episode of our miniseries 'COVID'S Lasting
Impact: Caring for Immigrant, Migrant and Asylee
Patients'. I'm Amy Liebman, MCN's Chief Program
Officer for Workers, Environment, and Climate,
and today we're going to be discussing what's
happening with COVID-19 and other respiratory
infections like RSV and influenza. We'll touch
on the JN.1 COVID variant and prevention
strategies such as vaccines and antiviral
treatments. With us today is MCN's Chief Medical
Officer Dr Laszlo Madaras. Dr Laz is responsible
for oversight of MCN's clinical activities. He's
our subject matter expert and is responsible for
topics such as migrant and immigrant health and
does a lot of our education around COVID-19. He
received his MD and his Masters in public health
from Tuffs University School of Medicine, and he's
worked all over the world including on the Congo
Rwandan border during the 1994 Rwandan Genocide,
and since 1996 Dr Laz has worked as a board
certified family physician in both inpatient
and outpatient medicine settings. He has served as
a frontline clinician at Keystone Health Center,
a community health center, where he cared
for migrant farmworkers and their families.
From 2001 to 2005 he served as the Assistant
Medical Director there and then he became a
hospitalist in south central Pennsylvania where
he continues to work today. In in his role as a
hospitalist he has treated thousands of
patients with COVID-19. Welcome Dr Laz!
[Madaras]: Thank you Amy, and it's great
to be here. I would like to just talk a
little bit about our experiences here with
patients with COVID. Like you said, Amy,
I have worked with the migrants and farmworkers
in and around south central Pennsylvania,
mostly in the Gettysburg area. And this included
the last four years where COVID has hit really
hard in our communities. And we're only about
four hours from New York City and our experiences
were not as drastic as as New York but it was
quite significant. And I work in a population
in Chambersburg Pennsylvania about 22,000 people.
And at the very beginning of this pandemic we have
about 22 ventilators and this really means that we
had about one ventilator per 1,000 patients in the
Chambersburg area when this pandemic began. So it
was really challenging for us to anticipate this
wave of COVID patients - and especially among
our most vulnerable patients which were, again,
the migrant workers who did not always have
access to care and who lived in trailers and
couldn't really isolate. Since that time, I think
our group of hospitalist physicians has worked
with and treated over 5,000 COVID patients. Most
of them in the last couple of years, thankfully,
have recovered and have done well. But those
first few years were very very challenging.
[Liebman]: So, I guess, do you want to give us
a little snapshot of what you're
seeing in Pennsylvania right now,
and then maybe comment- is that what you
think is happening nationally as well?
[Madaras]: Sure, sure. So in south central
Pennsylvania, you know, we have a 260 bed
hospital where I've been working for the last
many years - both inpatient and outpatient.
And in the last year we have seen COVID become
less lethal but more virulent - so easier to
catch. But thankfully we have not had to
intubate and put on ventilators as many
patients as we had during those first years
before we had a vaccination program started.
[Liebman]: Right, so right now, today is
January 24th. Are you seeing RSV along
with influenza and COVID? What are you seeing
when you're going into the hospital right now?
[Madaras]: So we do have influenza,
RSV, and COVID. Now some people get
two of these three viruses, a few people
actually get all three of them. So you can,
you can get the tridemic as you can say - that
this is what we're experiencing. Although, I think
it's important to also mention that this influenza
season is not as bad as other influenza seasons.
[Liebman]: Would you say it's safe to say
that right now what you're seeing is sort
of our traditional influenza season, maybe not as
bad as it has been in the past years. You're also
seeing RSV. And those are more seasonal.
And then on top of these seasonal moments
that we're having with these two infectious
diseases, we're throwing a new wave of COVID,
which isn't seasonal, on top of that.
Is that, is that what you're seeing?
[Madaras]: Yeah, yeah. It is something that
I think we could say we have a vaccine for
each one of those three, and if you take those
you're much less likely to have to see me in the
hospital, and I'll be much less likely to have
to intubate you and put you on a ventilator in
our Intensive Care Unit - and you're much,
much, more likely, if you're hospitalized,
to leave the hospital healthy. And then, in
addition, you're much less likely to get long
COVID, and if you do, it's much less of a severe
form than if you had not gotten vaccinated.
[Liebman]: So even though we're seeing
maybe not as much COVID as we've seen
in previous waves, does COVID remain
one of the leading causes of death?
[Madaras]: Yeah, unfortunately that is still
true. And our most vulnerable patients that we
see are those over 65, and even more so over
75. Those patients who are most vulnerable
should be vaccinated because COVID is still a big
killer. I also have patients right now who have
chronic lung disease and fibrotic lungs, and all
sorts of different diseases that hit the lungs,
and if they require already, at home, supplemental
oxygen, they're much much less likely to tolerate
an infection - much less two or even three
viral infections - on top of that. So those,
again, people with comorbidities as
we call them, such as lung disease and
kidney disease and liver disease, those are
the people that will become most vulnerable
to an attack from a virus because they have
less to fight back with, less resistance.
[Liebman]: So, I was just reading today that
about 20% of our adults are up to date on their
vaccines - that's really low. And only about 41%
of those who are over 65 are getting vaccinated.
And then when we look at our nursing home
residents only about 37% are up to date on
their vaccines. That seems really low to me.
And so, should we be concerned about that?
[Madaras]: Yeah, I think we should. I think,
those are numbers we can certainly improve on.
And I think - thanks to your help here - I got
information just recently on England and then
Denmark and other places where, you know, they are
doing a better job than we are of vaccinating our
elderly. And it's really important I think to get
those numbers up because, again, we don't want to
see a lot of people getting sick. And like I
said before, you know, our small hospital has
22 ventilators. Once we have everybody on a
ventilator, you know, this is just a terrible
situation where, you know, if you don't have the
vaccine, and you get really sick, and we're full,
I don't know what we can do for you at this point.
So best to get vaccinated, best to wear a mask
when you're sick, and isolate from those who are
even more vulnerable than you are. So I know we've
just had the holidays in December, Thanksgiving
in in November, and we did see a spike in cases of
COVID, cases of influenza, and cases of RSV. And
interestingly, years before this when we were all
masking and we were all using PPEs and all that,
the rates of influenza those years, the rates of
RSV, seemed to have gone down significantly
as a beneficial side effect of, you know,
the precautions that we were taking. So we know
these precautions actually work. But it's just
being able to get the public to, you know, adhere
to those recommendations, that is a challenge.
[Liebman]: So we have some tools. We have an
effective vaccine, right? And also that vaccine,
it might, you know, not keep us from
getting infected, but it's likely to
help us stay out of the hospital and
hopefully certainly not die - although,
you know, some people have a lot of other
comorbidities. But does the vaccine, and being,
and simply trying to prevent being infected, is
that is that going to help at all with long COVID?
[Madaras]: It should help. Our data coming in now
say that the people who've had long COVID, they do
much worse if they got COVID because they were not
vaccinated. The vaccination kind of dampens down
a little bit some of the inflammatory responses
that the body has when you have COVID. And so the
result of that is that we do have fewer cases of
long COVID and they're less intense in general.
[Liebman]: So we have this new variant, JN.1,
tell us about that and how our
vaccines are working with it.
[Madaras]: So JN.1 is, I guess, one of the
offspring of BA2.86 and there's a lot of
variants that become variants of interest to
us. And some of these, like Delta and Omicron,
in the past have really changed quite
a bit their response. In other words,
people who have had Delta could still get Omicron
and people have Omicron still can get this JN.1
variant. So when there's a great shift in the
spike proteins then we realize that we have to
update our vaccinations as well. And luckily, all
the vaccines that are available now the Pfizer,
the Moderna, and the Novavax vaccines, are all
effective against the JN.1 variant. That just
really came to life around last fall. And over the
last couple of weeks we've seen the percentage,
you know, it sort of dominates the picture.
Right now I think it went from like 36% to
65% to somewhere in the 80 percentile now
of the COVID virus that we are seeing.
[Liebman]: I want to take you back to the vaccines
for just a second because you mentioned our,
you know, basically in the fall we got this
new and improved vaccine. And, we can still,
and I'm really pleased to say that you're
telling us, that this new vaccine remains
effective against the latest variant, the
JN.1 variant. And you mentioned that there's,
you know, our Moderna and Pfizer vaccines,
which are great. And then you mentioned this
new vaccine, Novavax. Do you want to
just tell us a little bit about that?
[Madaras]: Yeah, so Novavax is a protein based
with an adjuvant that helps stimulate the immune
system. It's monovalent and we don't have
the bivalent vaccines anymore. So we have,
it's targeting now the latest variants that
we have. It is quite good. Moderna and Pfizer
are both mRNA vaccines, the Novavax is not.
I think if you've had side effects from the
other vaccines this may be the one for you.
I know people are frustrated that, you know,
a Tetanus booster you get once every 10 years,
you know. An MMR vaccine you get for your kids,
and it's like two times, three times, and
you're done. And this one, you know, we're
going to have to do more work and we're going to
have to take more vaccines than we thought. But,
hey, we had the influenza vaccine for a
while and we just got used to the fact
that we have influenza and it changes. You
know, it's outer surface proteins change
and this is how some viruses behave. So we
try to work with the best science we have.
[Liebman]: Absolutely. I still remember the
miracle of these vaccines and then crying
when my I knew that my 80s something year old
mother could get her vaccine. That was just an
incredible scientific breakthrough there. So,
vaccines are really important tools. They help
prevent severe disease and hospitalization
and death. We may still get infected,
but we're not going to be as sick. What else can
we do to protect ourselves from getting COVID-19?
[Madaras]: So, again, if you are around patients
who are sick, like I am in the hospital - I always
wear a mask. It's best to wear masks in public.
If you have a somebody who's sick you want to
protect them from getting something that you
brought in and you also want to protect yourself
from other people around you. Handwashing and
social distancing are still very good. If you
feel like you're getting sick it's best to try
to get a home test and test yourself. If you
feel like you've been exposed, you know, at that
point, as per the CDC recommendations right now,
for the next five days, you know, wear a
mask and test yourself. After those five
days if you're still testing negative, still
wear a mask, but you're more likely not to be
sick at that point. But I'd test again at
10 days and then see if you're ready to,
you know... At that point if you're not sick
that's great. If you test positive and you're
symptomatic then it's time to really stay away
from the public and stay away from, you know,
your grandma who might be sick. So, an N95 mask
is the best. We call those respirators rather than
the surgical masks. I wear those in the hospital
but I have the benefit of you know working in
a hospital where we do wear those masks all the
time when there's any respiratory virus right now.
[Liebman]: Okay.
[Madaras]: Yeah.
[Liebman]: Yeah that's so great. So, I just wanted
to a little commercial break here like letting
people know that at the MCN website we have a lot
of resources on a number of things that you just
touched on. 'What to do if you've been exposed',
we have information about getting a test... So
please visit our COVID Hub. There's a lot of
really great up-to-date information there. One
last thing, I just want to touch on because, you
know, it's still COVID, we're still dealing with
it. But, we learned about the airborne aspect
of this disease early on, and so, can you just
let us know if you still think ventilation and
air flow is important to preventing COVID-19?
[Madaras]: Yes. I think as you assess
your risk in any public situation,
you have to ask yourself, you know, is this
a well-ventilated area, is it open? I mean,
right now for the Pennsylvania winter, everything
is closed. So if you're in a closed environment,
how long are you stay there? How densely
populated, is this a crowded arena of
people and are they sick? Or is anybody,
you know, obviously ill? And, again,
if you're spending a lot of time and it's not
ventilated, and you're not wearing a mask, you're
increasing your risk. It's kind of a progression
of risk that you have to take into account.
[Liebman]: And so, you know, we've talked a
lot about - we have these tools of prevention,
right? You know, limiting our exposure,
getting vaccinated, wearing masks,
thinking about ventilation. So, if we do get sick,
what about these new antiviral treatments that
are available? What is your recommendation?
[Madaras]: Yeah, so, there again, it has been an
interesting journey through all sorts of different
antivirals that we've had. The one winner that
seems to have been effective and continues to be
effective is the Paxlovid - the nirmatrelvir with
ritonavir combination. It's one pill. It's usually
300 milligrams of the one and 100 milligrams
of the other combined in one pill that you
take twice a day for five days. And it has been a
winner. It has really helped reduce symptoms when
symptoms are at the very beginning, usually in the
first five days, some people say up to seven days,
but five days into your exposure and you're
starting to feel a bit sick but you don't
need to be hospitalized yet. So Paxlovid is
one of the great winners and I'm still using
all that. Others have come and gone but that was
one of the best. Another one is Remdesivir. This
one is an IV intravenous medication, and we
give 200 milligrams of that the first day and
then we give 100 milligrams for the next four
days - usually five days - in the hospital.
There are outpatient centers where people are
not so sick that they need to be hospitalized,
but they're fortunate enough to have a infusion
center at in their location. You can give this to
them in three days, but it is an IV, and so
you go back for three days in a row and get
the Remdesivir. So if they've started that and
they got sick enough to come into the hospital,
I'll often add two more days to make it five days.
If they're in intensive care unit, in the past
we've given up to 10 days of Remdesivir if they're
intubated and sick enough, because when you're
intubated you can't take the Paxlovid really
and nor should you because you're past the...
[Liebman]: Right, right.
[Madaras]: And then, there's Molnupiravir which
is another medication that is out there. It's 800
milligrams twice a day. Also for five days. And
sometimes that is better for certain populations
for whom the Paxlovid is not the best medication
for other comorbidities that they may have. So
I know a lot of doctors are hesitant to give
Paxlovid because our elderly population are
the ones who need anti-coagulants like Apixaban
for example, or cholesterol lowering medicines
like the statins. And these medications are not
compatible with Paxlovid. So sometimes our doctors
are hesitant to give those Paxlovid to people
who need these other medications to survive.
So it becomes a little trickier. But, you know,
the way I practice, I would stop a cholesterol
lowering medicine for five days and give the
Paxlovid because the risk-benefit ratio weighs
heavily on giving the Paxlovid and stopping
the Statin for five days. That would be my
recommendation. That's what I do with my patients.
The other medicines the anti-coagulants might be
a little trickier and maybe the Molnupiravir is a
better medication for those situations. And then,
also, for some patients who have behavioral
health issues and take medications for that,
that's really challenging sometimes because
you have to come off those medicines,
and you often need to taper off those medicines.
But the Paxlovid, you know, you have that five-day
window. And by the time you get to taper off
those medicines they may not be, you know,
effective with the Paxlovid. So for those
people, the Molnupiravir is a better medication.
[Liebman]: It sounds like it's an important
tool that can save thousands of lives. So help
us understand a little bit - you're really
recommending these antiviral treatments,
they're a really important tool in
our toolbox, they save thousands of
lives. Should we be concerned about this
rebound, or tell us a little bit about it.
[Madaras]: Yeah, so the rebound is a real
effect, and it does seem to happen up to like
one in five - so about 20% of cases - they have
some kind of rebound. Not all of it is a very
severe rebound, and many people just have a very
mild rebound at that time. Now if that happens,
you start to feel a little bit sick again and
you're kind of disappointed that you're sick,
and it's just kind of lasting a little bit
longer. You should not take another dose of
Paxlovid or Molnupiravir or anything else at
that point. Usually something like a little
Tylenol or something like that to get you through
is the best thing to do there. But I still feel
like the benefit of the Paxlovid is that you get
less of an intense breakout of COVID. And that
will also be beneficial down the road if you're
considering long COVID because if you have this
rebound it is challenging to some people, but
having taken the Paxlovid you're still giving
yourself a huge benefit down the road. So
I would still say it's much better to say
'I'll take the medicine' rather than saying 'well
there might be a 20%, you know, rebound'. But 80%
of people don't have the rebound, and you have
a huge amount of benefit from that situation.
[Liebman]: Yep. Well, that has been so helpful.
You gave us so much information to think about.
COVID's still out there. We need to remember
that we have a lot of tools available to us.
We've got the vaccines, we have three options
for vaccines. We also have some of our old
tools. Our N95 respirators can really make a
difference. And we know that ventilation and
thinking about sort of the space that we're
in as we assess our risk is really important.
You also talked a lot about the fact that our
elderly are still the ones that are most at
risk which hopefully is a motivator for all of us
to think about those who are at risk from still
getting very sick or dying from this disease.
And so those vaccines are going to make a huge,
huge, difference in that. And then should
we get sick we've got antivirals available
to us. We have a lot of tools that we
just did not have in March 2020, right?
[Madaras]: Yeah. I think we've come a long way.
And we've dropped some of things that didn't quite
work like the convalescent plasma. We thought
that was a good idea. It sounded good. But,
you know, we have to follow the science.
And I understand for people it's confusing
because you're recommending something at
one point, and you're not recommending that,
and you're going to something else later.
We have to follow the science and see what
works. So when the evidence points to
something not working, well then we'll
change course here. One of the other things
I want to mention - I don't think we talked
much about Pediatrics. These vaccines are good
for even, you know, younger children. And so,
I would say, please get your children vaccinated.
I know we focused a lot on the elderly here,
but I really do feel... I think both Moderna
and Pfizer are for 12 years and older. And the
emergency use act has also allowed that to
go down to six months of age and above. So,
at this point, six months to 11 years is okay for
the vaccines of Moderna and Pfizer at this point.
[Liebman]: That's a really important point to end
on, that even though we're looking at these really
different kinds of death rates, getting sick is
not fun at all. And having your kid hospitalized
because they're sick is really not fun. And
you don't want to see them in the hospital,
so, particularly when we have all these tools
available to us. I just wanted to make a,
first of all, I want to thank you so much for
your information, it was incredible. And also,
always so grateful to you for the work that
you're doing on the front lines in the hospital.
Not only are you saving lives but you're taking
that information and you're bringing it back to
Migrant Clinicians Network and helping us really
understand this disease and what we need to do to
prevent it. I do want to remind folks that we
have a lot of resources on almost every single
topic that we talked about today in our podcast.
It's on our website at migrantclinician.org at
our COVID Hub. And we also have a Frequently
Asked Questions award-winning blog that Dr Laz,
and our writer Claire Hutkins-Seda, and MCN staff
contribute to. So there's all these resources for
you at MCN. And I want to thank all of our podcast
listeners for joining us today. And I always love
talking to you Dr Laz. I do want to let folks know
that we have another upcoming webinar as part of
our Pfizer series that will be on Thursday,
February 29th. MCN will be hosting a webinar
with the National Hispanic Medical Association
featuring Dr Eric Russell who is speaking about
COVID and pediatric patients. So you gave us
a nice little segue into that webinar Dr Laz.
[Madaras]: But I also want to thank you and our
podcast team here because you guys make it look so
easy. There's a lot of hard work that goes behind
this. And I think we have a really deep bench,
so I feel really honored to work with MCN. And you
guys always point me in the right direction if I'm
looking for something I haven't quite found
yet - trusted leaders in public health. And I
think that's really important because there's
so much misinformation and disinformation out
there. I'm really glad to be able to work as
a physician right with a COVID population that
needs medical care, and also, working with
MCN to bring that message out and, you know,
work with our vulnerable populations
across the United States and globally.
[Liebman]: Great. Thanks Dr Laz and thanks to our
podcast listeners. And, I mentioned our website,
but you're also free to connect with
MCN on LinkedIn, Facebook, and X - or...
[Madaras]: Twitter, X...
[Liebman]: Twitter, yeah. We're getting
information out to you both in English and
Spanish in all sorts of ways. So please take
advantage of those resources. Thanks so much.
[Madaras]: Thank you.
[Outro]: To access resources mentioned in
today's podcast click on the link in our
notes section to go to our podcast page
at migrantclinician.org/podcasts. Visit
migrantclinician.org/signup to join our email list
and subscribe to our blog to get updates on new
MCN podcasts, resources, and webinars. Migrant
Clinicians Network is a national non-profit
dedicated to providing practical solutions at
the intersection of vulnerability, migration,
and health. We offer technical assistance, health
provider capacity building, resource development,
research, and data and evaluation support, and
virtual case management for mobile populations,
and free resources and training. The
information in this podcast is for
trained healthcare professional education
only. Information should only be used in
combination with up-to-date national and
international guidelines. The information
is not to be used as healthcare
advice for the general public.
