Wellstar infectious disease expert on boosters, long COVID, monkeypox and more

Jun. 14—In December 2021, the last time the MDJ sat down with Dr. Danny Branstetter, Georgia was starting to experience the rapid spread of the omicron variant of COVID-19. The variant exploded around the holidays, leading to a fresh flood of COVID patients, and causing worker shortages across the economy.

On Friday, the MDJ checked in with Branstetter, an infectious disease specialist with Wellstar Health System, to get the latest. In this Q&A, Branstetter spoke about shifting from a pandemic to an endemic, keeping up to date on vaccinations, and that new headline generator — monkeypox.

MDJ: Where are we in the pandemic, nationally and locally? Should we expect another surge, or are we finally kind of approaching normal?

Dr. Danny Branstetter: So I think we are having what a lot of people are terming a soft surge. We are seeing an increased number of positivity in our community, and probably have been over the last couple of weeks. We did hit a nadir of around 2% positive in the community on our lab testing, which is really good. We also saw a nadir in our hospitalizations. So we were doing really well, less than 50 throughout our health system. And now we're double that.

So we're slowly creeping up over the last couple of weeks, probably because of Memorial Day, travel, gatherings, school's out now, a lot of kids in day camps, those kinds of things. So we are in a place where we're seeing a lot of spread still in the community. But we're not seeing a huge amount of hospitalizations, which is great news.

So we're moving toward more of that ongoing infection in the community, without the sense of so much disruption in our daily lives, disruption in the supply chain and our ability to provide health care, ability to provide environmental services such as trash services etc., in our communities.

Is this more toward a new normal? I would say yes, this is more and more what we're expecting to see in the community — ongoing transmission, ongoing risk, need to get tested, need to get treated, need to stay up to date on your vaccinations.

Q: How should people be thinking about their personal risk level? What are you personally doing, in terms of risk mitigation, and what do you think people should be considering?

A: Yeah, so I think it really is looking at your own personal risk and what you are having to deal with in your life, not only from a personal risk, but who else you may expose in your life, from that standpoint. So for me, personally, I still wear a mask on a plane, I wear an N95 when I fly, but I'm getting out and doing things. I've started eating in restaurants again, which is something I had not done throughout the pandemic. So those kinds of activities, I think, are reasonable. The large gatherings, the thing that I really am telling people is, they are turning out to be super spreader events ... even retirement parties and birthday events, graduation parties, all these do see an uptick in cases of people who attended.

So in doing so, if you participate in those, have your home test, talk to your primary care, get tested. And definitely make sure you get treatment if you're in the high-risk categories. And please stay up to date on your vaccinations, I want you to enjoy these events, I think that's the right thing to do. But make sure that you are being safe.

The one word of caution that I'm hearing way too much that really disturbs me is 'It's just my allergies' and 'It's just a summer cold.' Right now, the summer colds are COVID. So please get tested and please get treated. The treatment not only helps you, but also prevents you spreading it to others in the community. So definitely make sure you do that.

I hear a lot of pushback on vaccination, 'if I'm going to get it anyway.' Remember: vaccines prevent us from dying from this, and getting severely ill, and needing to be in the hospital, developing complications such as long COVID, which is something we want to avoid in everyone. So the vaccines benefit everyone in those regards. Even if you survive or have very mild symptoms, the vaccines do help us get through that much quicker. So please stay up to date on your vaccines. And we should hear, less than five-year-olds, probably in the next couple of weeks, a decision on vaccines for those.

Q: Right now, it's recommended if you're over 50, or if you're under 50 and immunocompromised, get a second booster. Is there anything else you would say to people who are maybe undecided about boosters? How much will it help?

A: So the general rule of thumb is everyone needs at least one booster, the data is very clear on that in omicron. So if you haven't gotten that first booster, and you're out at least four months, probably six, definitely get that first booster shot under your belt. It helps provide that long-lasting protection.

It's not unexpected that we need these, right? Upper respiratory infections such as influenza, particularly viral infections, like COVID and influenza, will need boosting, will need repeat dosing of the vaccines. We do that every year for flu, and that is why we do that, is because we need that repeat dosing to give us the maximum protection. So that's the first message there.

When do I make an adjustment, if I've had COVID? So certainly that COVID infection gives you a boost. Certainly, that gives you a level of protection for a period of time, not lifelong, that's very, very clear. Just like the vaccines don't do lifelong protection against those. So if you've had COVID, I would not wait longer than six months before you're getting that next shot in your series, wherever you fall, whether it's your second shot, your third shot, or even your first shot, I wouldn't wait longer than six months, probably the sweet spot is after three months. So if you've recovered from COVID, look at getting that next shot that you're in line for about three months after.

Q: On the topic of kids getting vaccinated, the FDA is supposed to approve vaccines for kids under five years old. Do you recommend that people get their little ones vaccinated?

A: My first plea is we have the vaccine recommendations for five and above, and very low national uptake of that group. And so I think that is a very important group, particularly those who are in school and around kids and want to do all those activities around others, and do so without a mask on and the close contact. So those are hugely important. ... Omicron saw the largest number of kids, it was the mildest form in most people, but it saw the largest number of kids hospitalized. So these variants are impacting kids. And omicron did more so. And the variants of omicron which we're seeing right now circulating are highly contagious, very, very contagious, and impacting kids more than any of the other variants we had seen. So it is really the prime time to get younger people vaccinated, as the impact of COVID is (seen in) that age group more and more.

I'm excited about less than five, because that's the last group that we don't have that level of protection. And certainly we are seeing complications related to COVID from those. Not the majority like we do in older adults, but certainly that is something that we'll be able to finally give, that level of protection, so people can do more and be more relaxed at the complications of COVID such as death, hospitalization, severe infections, are mitigated as much as possible with these vaccines.

Q: Another thing that's come up recently is this Novavax vaccine. I understand it's more of a traditional vaccine. I was wondering if you could speak a little bit about what you know about Novavax, and might it give some people more assurance, people who had been hesitant at first?

A: So remember, vaccines, they expose our immune system to part of a virus that we're trying to protect from in some fashion, and then that allows the immune system to respond, make antibodies that then help prevent severe infections and death. And the RNA vaccines use that technology to make our body produce protein for a very, very short period. So our body will respond to it, it's called a spike protein.

The adenovirus Johnson and Johnson vaccine — AstraZeneca is the one available over in the UK and Europe — those provide also a spike protein antibody, but it's a little bit different in how they get it to us. But it's still the spike protein that's the important part in doing that.

The Novavax actually provides the actual protein for the body to respond to. So, all the same concept, but just a little bit different mechanism by which it delivers that piece of the virus for our body to respond to. The Novavax is built on what we would term as older vaccine platforms or older vaccine technology, more the traditional vaccines that we have seen in the past. So it does give us another option to allow us to get patients protected. And so we should hear about whether or not that gets approved. It will probably get approval, it'll probably need booster dosing, just like we see with mRNA vaccines.

With that, there's other news that I'm excited about — that is allergies. So people who had trouble tolerating mRNA vaccines, or had a side effect issue, or (were) precautioned not to take it, this gives them another option to provide even further protection later down the road. So this is really exciting news that we have another option. And the storage may allow us to get into other communities that were having issues with the supply chain because of the storage requirements for the mRNA vaccines.

Q: So the Novavax, in terms of storage, does it not have to be kept really cold?

A: That's correct. It doesn't need such cold storage as the mRNA vaccine.

Q: How has Paxlovid and other treatment drugs that have come out that we didn't have a year ago, how has that changed your job, and the job of other physicians, in treating people that have COVID?

A: One of the things we really knew first off, in our experience with influenza and other viral infections, is the earlier we treated in the course of illness, the better chance we had to avoid the complications. So outpatient treatment was the key. And we really didn't have that early on in the pandemic, in 2020, for example, did not have that option. Now we do.

So we have the ability to test really early, home tests, and a quick test is available at a lot of locations in the community. So getting that diagnosis, and then getting started on treatment that is effective ... And that has been very effective at reducing complications and hospitalizations, with or without vaccination status.

So it's very important though, it's the early diagnosis, early treatment is key. That is really, to me, a game changer. It allows us to do things safer. ... Because it's circulating so much, the risk that we're all getting exposed and have the chance to develop an active infection, is very, very high. And with the contagiousness of these recent strains even higher, the option to be able to treat with these oral antiviral agents such as Paxlovid in the outpatient arena, is really, really helpful to keep our community healthy, and allow us not to have all the disruption that the pandemic has brought us.

Q: You mentioned long COVID. What do we know about long COVID? How common is it? What symptoms are most common? How long does it last? I know the medical community is still trying to get a handle on all that.

A: Yeah, so what we know is we don't know much yet. We're facing a lot of the same questions that you just mentioned, and it feels like 2020 all over again, when we were trying to figure out COVID itself, and now long COVID. As far as incidence and who gets it — way too many people. It can vary from prolonged abnormal sense of taste and smell, to brain fog, trouble concentrating. You may have other deficits such as numbness and tingling. I know some people have neuropathy, stinging in the hands and the feet. Those can be ongoing. And then the overwhelming fatigue that some people get, it can be debilitating, really preventing return to work, and sick days, and just quality of life is significantly impacted.

The duration is so unpredictable. Some people have it for a few months. Some people still have it ongoing, and it has not stopped. We can't predict who's going to have these complications. That's why I've been so passionate about getting people vaccinated and early treatment. Because I cannot predict if you or me ... will have long COVID... You can get long COVID if you've had COVID before, and didn't have it for that first episode.

Just because you survived it once, didn't have any complications, doesn't mean you're going to not have long COVID again. So my caution is, do everything we can to protect ourselves from things that we want to avoid. And that is this disruption in our lives, disability, and, certainly decreased quality of life from this infection that could be long lasting.

Q: What are things like at Wellstar and at Kennestone Hospital? When you were at the peak of omicron, if that was a 10 out of 10, swamped with patients, what are things like now?

A: Much better from a COVID standpoint, as far as volume of patients, number of people who have severe illnesses, it's night and day difference. And that's palpable. What we're dealing with now in our own environments, and we're seeing that across the communities, not just within healthcare ... is just the burnout. Really, the need to recover from the disruption that COVID caused us. And all the worker shortages, the being tired, the essential workers out there doing everything every day. And just trying to get some sense of relief from all this disruption and mayhem that they've dealt with for a prolonged period of time, that no one knew that we would deal with, 24-plus months now.

So I would say what we're experiencing is some relief from the severity of COVID. Still ongoing cases, but really struggling with how to now deal with recovery and support of our team members and our communities as we are trying to get through, and get finally past all the mayhem and get some of that "normalcy" back.

Q: You said cases have been slowly creeping up. I think we're at double the number of cases that we were at a month ago. Where do you see that going? I know it's hard to make predictions.

A: I think that my concern is that this will keep growing, right? As people are out from their vaccines, and out from their first bout of infection, omicron particularly, the recent one, as we get further away, the protection will wane and people are now doing more of everyday life, not taking as much precautions, forgetting to get that booster or not recognizing they need to get that booster. So I think we'll see that grow, that number grow because of that, that's my concern.

The thing that I think would be best is if we see this as 'uh oh,' a warning sign, and people make the minor corrections that are needed to really get this back under control. I think in the future, we'll see these numbers continue at a low level, or a lower level than our surge peaks.

Maybe now one-sixth, one-fifth, 20% of what we saw before... Hard to say, no one's got the crystal ball, so those numbers are just completely abstract. But I wouldn't want it to be, for our community, be any higher than that. No. 1, workforce, and No. 2, complications of COVID. But I think the good news is we have vaccines available, we have the treatment available, and it's readily available, early diagnosis with testing available, so we can get this under control really quickly, and prevent people from needing hospitalizations and the severe complications.

Q: A few months ago the CDC changed their recommendation to just five days of quarantine. Is that still, you think, a safe plan of action? Let's say you test positive on a Monday, Friday rolls around, and you pretty much don't have any more symptoms, and you're not sneezing. Are you good?

A: Yeah, I think you hit the key, right? The key is the symptoms. So if you're still having symptoms, stay home. Stay home, you need to recover yourself, take care of yourself. So that's the first thing.

The second thing is, the key factor that often gets dropped in that conversation, is there's still a recommendation to mask ... around other people for five additional days. And I'm not seeing that. I am not seeing, with the number of infections we have in the community, an increased number of masking people out there, because they've had it and are now still in the recovery phase. We're still needing to be cautious of transmitting it to others, because that's still possible in that day six to 10. So is five days right? Yeah, absolutely. But we've got to take those other steps in order for that to remain the right thing.

Q: Is there anything else you want to mention that you think people should know about the state of COVID?

A: I think it's here to stay. I think we have moved from our pandemic phase and what we call the deceleration phase, and more in the moving toward the endemic. That's No. 1. So we are moving out of the pandemic. I think the public health emergency, we're still in that at least through July 15, probably longer, as we've been told that we'll get a 60-day heads up on the public health emergency. So I anticipate it will be renewed for another 90-day block in July. And that'll take us to fall. Fall's a big time that everyone's really concerned about this. I do anticipate there'll be an additional recommendation for vaccines for everyone in the fall. So look for that, along with our influenza shot. This will be all age groups, there will be more options available this fall like the Novavax, there'll be other options for kids, even less than five, I do anticipate. So as we prepare for school, as we prepare to return to college, getting back to work and working in person, I think all these things are important to pay attention to, to make sure that you're able to stay healthy, enjoy the holidays, family, gather and celebrate life. And finally really get us into that endemic, meaning it's here to stay, still going to circulate in our community. But we're able to live our lives and not have the disruption that this has caused us.

Q: What about monkeypox? How worried should we be?

A: So we're going to see monkeypox. We've seen one case confirmed here in the state of Georgia, we will probably see another few cases here in Georgia, it wouldn't surprise me at all. It's a big international travel city. Most of the monkeypox within the United States, we're now over 30 cases confirmed in the United States, most of those have been international travel exposures, or someone who has internationally traveled.

The good news is, this is not going to become a pandemic. ... Monkeypox is not transmitted to the degree with which COVID-19 is transmitted. It's not that type of viral transmission. So it is not going to become a pandemic. Second thing is, we have vaccines that are effective against that already. So as we have people exposed, getting post-exposure prophylaxis with vaccines is also effective at preventing the illness as well. So we have many options that will prevent this from becoming a global pandemic as well.

We'll see some outbreaks, probably clusters, more cases. And that wouldn't be surprising at all, but I don't think this is going to cause us another headache for two years like we saw with COVID.