Paul Sax
@PaulSaxMD
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Harvard/Brigham Infectious Diseases doctor, writer, @CIDJournal editor, educator. Prefer baseball to football, pizza to sushi, dogs to cats, Beatles to Stones.
Boston, MA
Joined April 2009
Lots of questions about the Covid-19 vaccines -- here are some of the more common ones, with my answers. Directed at clinicians, but probably something here for all. Any that we missed?.@NEJM
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Pictures like this make me feel more patriotic than any flag waving.
Kamala Harris’s immigrant parents--Shyamala Gopalan and Donald Harris:
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It wasn't easy writing this. Thanks to @PreetiNMalani for allowing me to share it. Rosa via @JAMA_current part of @JAMANetwork
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About a year ago, I thought ivermectin *may* have a role in treating Covid19 based on promising preliminary results from a meta-analysis. Here's what happened, along with a key figure -- and an apology for a mistake (mine). Latest:
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Apologies for bragging, but I'm the proud owner of a new degree. Cc'ing @NobelPrize , just in case this was the one missing piece.
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Iceland recapitulating what South Korea found -- incidence of #COVID19 actually higher in younger adults, hence playing a major role in spread (and occasionally causing severe disease too). But symptom-driven testing (Netherlands) finds more cases in older populations.
Here is a distribution of recorded Covid-19 cases in Iceland (which tests broadly, even people with no symptoms) and the Netherlands (which tests narrowly, only those with severe symptoms)
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The "History of HIV" talk I gave last week actually has this title, which I don't think is an overstatement. Posting it now with gratitude, just in time for Thanksgiving (my favorite holiday -- the gratitude and family part). (Part 1 thread).1/x
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The FDA authorization of the Pfizer vaccine for 12- to-15-year olds has triggered concerns among even some very pro-vaccine (and very smart) people, who wonder if their kids should get immunized. Here's why I support it, which is way too long for one tweet.
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If you're in ID right now, you know that life is . kind of nutty. Tried to outline a bit what it's like. What Does (And Doesn't) Scare Me About The Coronavirus via @commonhealth.
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*Strongly* recommend this comprehensive review of just how much COVID19 vaccines reduce the risk of transmitting the virus to others. Tell the hesitant: the vaccines protect both you and protect others -- a lot! @mugecevik @AaronRichterman @EricMeyerowitz
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With so many breakthrough cases, some might wonder why we still should be pushing vaccination -- in particular that third dose. Outstanding summary here, thanks to @EricTopol
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Antibody testing shows that SARS-CoV-2 infection is 50-85 times higher than confirmed cases. It will be fascinating watch these seroprevalence studies roll out over the next few weeks. (And by the way @samhorwich, well said!).
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Why are Covid19 case numbers dropping? It's probably multi-factorial -- in other words, a gemish* -- and pretending otherwise might get us into trouble. Because there's a lot about this virus we still don't know. Latest post:.*word defined in the post.
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Today we mourn the loss of Dr. Francisco Marty, a brilliant clinician, clinical researcher, teacher and photographer. He taught us so much. My heart just breaks.
Hoy en la ciudad de Santo Domingo, República Dominicana, murió mi hermano mayor Francisco Miguel Marty Forero por un accidente, prestigioso médico venezolano infectólogo, PAZ A SU ALMA
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One of the great things about the @JoeBiden appointments so far is that they have been based on talent, character, and achievements. Here's a prime example.
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“Vaccinated people are just as likely to spread the coronavirus.” . This isn't true. But some people -- even some very smart people -- mistakenly believe this. Dr. @Craig_A_Spencer explains here why, in this really good piece from @TheAtlantic.
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Thank you, @IDSAInfo -- am really excited about this new opportunity! And also thanks to Dr. Chip Schooley for helping with the transition. Hey #IDTwitter -- what do you want to see in our flagship clinical journal?.
IDSA is pleased to announce that @PaulSaxMD has been named the next editor-in-chief of Clinical Infectious Diseases. 🎉. #IDSAJournals #ClinInfectDis
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What's more ID than writing an HPI that starts, "Briefly . " . and then following it with a 1500 word note?.
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With vaccine effectiveness waning, case numbers rising, and no concerning safety signals from boosters so far, is it time to recommend a booster for all adults? .Here I argue yes. Plus, simplifies @CDCgov guidance. Latest: @drlucymcbride @EricTopol.
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Retrospective analysis (just out in @CIDJournal) of Paxlovid Rx in vaccinated high-risk outpatients shows a strong association between treatment and improved outcomes. Thanks to @SarjuGanatraMD & @SaurabhSDani for leading this interesting study.
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The automatic greeting to every ID doc:. "Can I ask you a quick question . ?". Though the question is quick, the expertise required to answer it is a lifetime of learning. How can we make this recognized -- and justly compensated -- in our healthcare system?.
Everybody wants to talk to or curbside an ID doc about COVID but ID still remains one of the most under filled fellowships along with being chronically overworked with added stuff like hospital infection prevention/control and amongst the least compensated fields. Must change.
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This is quite the figure, from a @CDCgov presentation. Further evidence of the critical role of humility when it comes to predicting what's next in this pandemic, a lesson we all need to learn again and again. H/T @washingtonpost
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Wow. Extraordinary graphic of proportion of drug revenues by disease area over time. Main story is about Cancer, but note early DAA era (Infection) and shift to INSTI-Rx (HIV) -- big advances with big prices. h/t @manfordou .
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The analogy here with HIV by @zeynep is quite compelling -- specifically that most HIV-related deaths occurred *after* we had effective ART. The same might be true about Covid and effective vaccines, unless distribution rapidly improves.
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Thank you, @CDCDirector, for overruling this tone-deaf ACIP vote, so it now aligns with FDA panel. Her action might also be motivated by the terrifying front-line experiences she had with this dreadful disease (though she did not say this). A lesson in good leadership
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Pip-tazo plus vancomycin has been implicated in numerous studies as a cause of AKI. But is this in part a pseudo-association? Mechanism: Pip-tazo inhibits tubular secretion of creatinine -- analogous to DTG, BIC, cobi, and TMP/SMX. H/T @BWDionne
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How about this strategy? . - Vaccinated travelers only.- Rapid antigen tests before boarding.- If negative, bon voyage!. No, nothing's perfect. But it's got to be better than the patchwork of conflicting rules and regulations we have now.
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How do we reconcile the conflicting remdesivir study results for treatment of #COVID19? Here I give it a try. h/t @AaronRichterman @EricMeyerowitz @mikejohansenmd @FranciscoMarty_ .
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We've made enormous strides in understanding how this virus is transmitted. Solitary outdoor exercise isn't one of them.
University of Berkeley has banned outdoor exercise, including solitary outdoor exercise, in response to a COVID outbreak. I had read the article to make sure this was not a parody.
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More exciting results from the TOGETHER trial in high-risk outpts with Covid19. 50%⬇️in ER/hospitalization with one subcutaneous dose of interferon lambda in a mostly vaccinated (!!!) population. Variant "agnostic." h/t @boulware_dr
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Ever submit a paper to a high-quality, high-impact factor journal and have it rejected, even though the reviews are mostly good and eminently addressable?. Certainly I have. 🙋♂️.1/x.
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With nirmatrelvir (Paxlovid) and molnupiravir not yet available, and the most widely used MAbs lacking activity against Omicron (+ other issues), is it time to bump up fluvoxamine at least to "consider use" status on the treatment guidelines? Two well-done RCTs show benefit.
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In June 2019, I posted here about the Editor-in-Chief of @NEJM: "You know those rare times when the smartest person in the room is also the nicest and the funniest? That's Eric Rubin. Plus, an ID doc, so there's that." Let's add to his credentials this:.
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When the history is written of how we responded to this threat, this graph will be featured prominently. ID clinicians, epidemiologists, scientists have called for more testing for weeks!.But . water under the bridge. Time to move to next phase, which is aggressive mitigation.
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I was trying to describe how Covid gobbles up all the time we ID docs used to spend on other stuff -- there are only so many hours in the day. Fortunately, my sister came to the rescue with a clever graphic, which explains it perfectly. Latest:
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Incomplete protection from prior infection isn’t what any of us want to hear. But as we’ve learned again and again, wanting something from this virus doesn’t make it happen. Latest: .Prior Covid Is No Guarantee of Immunity @TheBlondeRN @ashishkjha.
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This interesting lab work shows that Omicron may not be so great at growing in lung tissue. It's the second such study. Though it may be wishful thinking (ok, it is wishful thinking), could this variant really be less pathogenic?. Time will tell.
Sharing some potentially significant findings relating to Omicron given the current situation. First of all huge thanks to the team working flat out- Bo Meng, @isabella_atmf and to our collaborators both in G2P, J2P along with @SystemsVirology. Findings as follows:.
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Infection control specialists are among the most data-driven, careful bunch in all of medicine. If they're endorsing mandatory COVID vaccines -- along with the rest of the ID groups -- there's an extremely high likelihood it's the right move. We need to protect our patients.
NEW in @ICHEJournal: #COVID-19vaccinations should be required for healthcare personnel according to new recommendations from a multi-organization panel of infectious disease and healthcare experts. @APIC @IDSAInfo @HIVMA @PIDSociety @SIDPharm @AMDApaltc
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Congrats to @DGlaucomflecken, who gave the commencement address at @YaleMed -- and is the subject of this glowing profile on @JWatch. If you think I hope to encourage him to appear on a @CIDJournal podcast, you're 💯% right. But I also mean every word.
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Mild symptoms ➡️ Rx Paxlovid ➡️ improved, w/ negative antigen➡️ symptoms recur ➡️ antigen positive again. Why? Some ideas, not mutually exclusive:.- 5-day duration of therapy too short for some.- Treatment blunts immune response.- Antiviral resistance.- Reinfection.Thoughts?.
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The viral dynamics of Covid are dramatically different now than at the start of the pandemic. Prospective study: viral loads peak on day 4 of symptoms; rapid antigen tests are 30-60% positive on D1 & 80-93% positive on day 4. Immunity = "New Normal".
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I told @ErinMcCreary and @jpogue1 that a review of #COVID treatment might have a shelf-life between milk and yogurt, so it had to be done FAST. And wow were they fast -- and it's great! @SIDPharm @IDSAInfo
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Raise your hand if you find this incredibly annoying every time you look at an online published study 🙋♂️
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Some thoughts about why "everyone is so chill" (h/t @walidgellad) about Covid despite what's happening in Europe -- and why we ID docs remain nervous Nellies. Because we can hope that case #'s will be lower during a BA.2 surge, but we can’t count on it.
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Prevention of symptomatic disease without also preventing subclinical infection would be extremely rare for a vaccine preventable illness. Yes, let's see data. But would be enormously surprised if these highly effective vaccines didn't also make people less likely to transmit.
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An unbelievable loss -- my heart goes out to his family, friends, and co-workers. He touched the lives of so many people -- lucky to count myself among them.
#BREAKING: Dr Paul Farmer, a renowned American physician and co-founder of Partners in Health @PIH, has died aged 62. Farmer was a receipt of the National Order of Outstanding Friendship (Igihango), which he was conferred upon by President #Kagame in August 2019.
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What is the best Rx for toxo encephalitis? This comprehensive review of treatment studies in @CIDJournal suggests that TMP/SMX is as effective and safer than pyr-sulfa or pyr-clinda. Certainly is easier to give and much less $$$. Change in guidelines soon?
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People who volunteer for ethically done, scientifically sound clinical research studies are some of our society's unsung heroes. Well done, @MollyJongFast. 👏👏👏. I Am the Joan of Arc of Coronavirus Vaccine Trials
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Brilliant, as usual. Am tempted to write something about ID salaries vs ophthalmology salaries, but with these @DGlaucomflecken videos, he deserves every penny he makes!.
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The ACORN study of cefepime vs pip-tazo serves as a great lesson in how to do randomized trials in hospitalized patients. Now that we have this model, let's do more of this, please!. Here's why it's so important:.
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Attached a wonderful figure from my @BrighamWomens colleagues in infection control, just published. So important.
@mirvatalasnag @PaulSaxMD #IDtwitter what do you think of above WHO guideline. Can we consider a patient non-infective after 13 days despite a + PCR.
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Yes, agree with headline, for now. But the message to those considering vaccination should emphatically be:.1. Protects you!.2. Protects others!.Focusing on no "proof" of #2 in the data needs to stop. Broad use of these vaccines will reduce transmission.
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Our President hasn't given this speech yet, but we can hope, right? Sorry for going political here on an Infectious Diseases site, but sometimes one just has to. Never mind, I'm not sorry.
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Don't worry, everyone got the Regeneron antibody cocktail an hour before the party started.
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TOGETHER randomized trial: 11% (79/741) of the fluvoxamine group needed hospital care, vs 16% (119/756) of the placebo group (probability of superiority of 99·8%). Mortality in the per-protocol analysis: 1 for fluvox, 12 for placebo. Encouraging results!
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Strategies for management of recurrent UTIs, an incredibly challenging problem in ID and primary care. Great talk from @BWH_IDinPCARE course by @sigal_md, thank you!
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I was today years old when I learned this. Sharing to spare others the embarrassment of trying to pronounce "medRxiv" during an interview, group call, or other social encounter. @hmkyale @medrxivpreprint
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HPTN 083 is the HIV prevention study of the year (so far), and the results didn't get nearly enough attention when announced last week. So I'm taking a break from you-know-what to highlight this important trial in today's post. @HIVptn @doc_in_a_box
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Who needs multiplex PCR or next-generation sequencing when we have this? 🐕🐶.
Correspondence in June issue describes how trained dogs use their noses to identify people infected with the #malaria parasite
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Hey @ResidentFOX , my services to help you talk about infectious diseases without sounding dumb are available at a very reasonable price.
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Yesterday, at the International AIDS Conference (#AIDS2024) in Munich, we got one of those thrilling moments you hope for when attending a scientific conference -- but don't usually get! . Here's what happened. @LindaGailBekker @drmoupali .
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Shortly after publication, we and the authors learned that one of the studies on which this analysis was based has been withdrawn due to fraudulent data. A revised version excluding this study is underway, and the currently posted paper will be retracted.
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Spot-on analysis of this problematic report of long covid in people who (reportedly) never had symptoms during acute infection. Underscores many flaws, in particular the fact that we desperately need a control group -- again. @zeynep .
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This paper is so valuable. Explicitly outlines the trade-off between vaccine safety/side effects and protection from a *life-threatening* disease, using population-based data outside of clinical trials. TL/DR: Not even close. Get vaccinated.
1/.Vaccine safety: We compared excess adverse events after #COVID19 vaccination (Pfizer-BioNTech) and after documented #SARSCoV2 infection. Take-home message: Low excess risk of adverse events after vaccination, higher after infection. Some thoughts👇
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Well said, @CDCgov. The whole thing, but have highlighted something particularly important that often gets missed.
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Pre-print RCT of HCQ vs SOC. N=150, mild dz, young. - No antiviral efficacy (primary endpoint).- Possible resolution of symptoms faster in small subset w/ no other antiviral therapy.- CRP down more.Seems more an anti-inflammatory than an antiviral.
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John Bartlett just died -- a true visionary and the classic "Renaissance" person in clinical ID. Such a nice guy, too! His IDSA/IDWeek literature summaries (among other things) were amazing. We'll miss him! @IDSAInfo .
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Anyone discounting the importance of full @US_FDA approval of the Covid19 vaccines doesn't understand decisions about mandated vaccinations for:.- employers.- schools.Some hesitant to act without this step. Including @MassGenBrigham, where I work. Approval can't come soon enough.
U.S. FDA sets January target to decide on approval of Pfizer's COVID-19 shot
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Take-home lessons on use of doxy PEP for STI prevention by master of PrEP and PEP Dr. Jean-Michel Molina @jmmolinaparis as we await changes in guidelines. Outstanding plenary at @IAS2023.
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Given resistance to azithromycin and toxicity of fluoroquinolones, doxycycline for CAP has tremendous appeal. This systematic review of clinical trials suggests has comparable efficacy. @CIDJournal
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South Africa: Incidence risk and in-hospital mortality decreased in the Omicron BA.1/BA.2 wave, then declined even further in the Omicron BA.4/BA.5 waves. Covid19 is still with us, but the disease has dramatically changed. @nicd_sa @CIDJournal
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How about a randomized clinical trial? Two hospitals:. Sending out these "hospital and ER are full, discharge people faster" emails.vs. Investing resources to make more clinical services/tests available 7 days/week instead of 5. Endpoint: Change in length of stay.
Thanks hospital admin for emailing me our ER is full and I need to discharge more people and faster. Maybe perhaps it’s a holiday weekend and hospital always understaffs has something to do with it?.
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The next time someone adds an admin task to your workday, or an increased documentation requirement for billing and not to benefit patient care, send them this brilliant piece by @danielleofri, which is deservedly flying through the internet like wildfire.
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For certain infections, good quality randomized controlled trials are unlikely ever to be done -- hence the importance of large observational studies. This one is potentially practice-changing given the difficulties of high-dose TMP/SMX in some patients.
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Remdesivir, tocilizumab, sarilumab . covering some recent clinical studies here, while trying to grab a drink of water from Niagara Falls with a glass (a.k.a., keeping up with #COVID19 research). h/t Canadian @HelenBranswell for the analogy. Latest:
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Why should Covid19 vaccination be required among hospital employees?.- Helps the employee.- Helps patients.- Helps co-workers.- Helps public health.This really shouldn't be that hard. Latest: h/t @EricTopol @drklausner.
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More on relapses after Paxlovid. @Pfizer cited 2% in their clinical trial. Whether higher in clinical practice is unknown. Certainly, it *seems* that way -- but without knowing the denominator of total treated patients, we can only speculate. Latest:
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Time to bring out this important public message for clinicians everywhere
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Very hard to argue against these data, which look as good (if not better) than the original placebo-controlled trial. 6 vs 123 cases of symptomatic covid19. These 3rd doses (boosters) work really, really well -- and they work fast!.
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Must-read piece in the @nytimes by @DrMattMcCarthy on shortage of ID docs. Here's what must be corrected: "At many medical centers, a board-certified internist accepts a pay cut of 30 percent to 40 percent to become an infectious-disease specialist."
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That's why I'm delighted to announce that @CIDJournal -- and soon *all* the @IDSA journals -- will accept outside reviews from other high-impact journals. Some details in screen captures below. 3/x
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Since talks on Covid get out of date as soon as you click "save", might as well post the talk given this week at @harvardmed Medical Grand Rounds, along with by @k_stephensonMD @SanjatKanjilal and Dr. Ruanne Barnabas.Here's the topic:.1/x
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Yesterday I saw someone who had a CD4 cell count of 8 in the early 1990s. Today she works full time; she raised her two kids, went to their college graduations, has grandkids, etc. Which is the greater scientific advance? (FYI: her case is no big deal in HIV medicine.).
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Low vitamin D levels may correlate with worse outcomes in many diseases. But supplementing does not necessarily improve outcomes. In fact, it almost never does. (Still waiting for a truly convincing study in any infection.). Lather, rince, repeat.
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OVIVA: Oral antibiotics non-inferior to intravenous in osteomyelitis. In our (little) ID world, a definite practice-changing study, glad to see it.
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