COVID-19: Challenging Clinical Questions
Authors: Christine Laine, Darilyn V. Moyer, Deborah Cotton
Journal: Annals of Internal Medicine (2021)

Special ArticlesFebruary 2022COVID-19: Challenging Clinical QuestionsFREEChristine Laine, MD, MPH, Darilyn V. Moyer, MD, Deborah Cotton, MD, MPHChristine Laine, MD, MPHEditor in Chief, Annals of Internal Medicine Search for more papers by this author, Darilyn V. Moyer, MDExecutive Vice President and Chief Executive Officer, American College of PhysiciansSearch for more papers by this author, Deborah Cotton, MD, MPHDeputy Editor, Annals of Internal Medicine Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/M21-4611 Eligible for CME Point-of-CareCME/MOC SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail In October 2020 when Annals of Internal Medicine and the American College of Physicians hosted the first COVID-19 forum, we did not anticipate that the pandemic would continue through 2021 and there would be a need for continuing this forum series over a year later. Unfortunately, SARS-CoV-2 is a stubborn virus, an alphabet of variants has emerged, testing remains suboptimal, and pandemic fatigue and reliance on misinformation have resulted in too many people choosing not to adhere to recommendations for vaccination and other public health measures. The body of knowledge about SARS-CoV-2 that researchers have amassed since early 2020 is remarkable. Yet, as we learn more, new questions emerge. This is particularly the case in light of the recent recognition of the Omicron variant in late November 2021 and the emergence of promising antiviral therapies. On 8 December 2021, Annals and ACP convened 3 infectious disease experts to address current challenging clinical questions. Panelists included Dr. Sabrina A. Assoumou from Boston University; Dr. Judith S. Currier from University of California, Los Angeles; and Dr. Jeanne Marrazzo from University of Alabama at Birmingham.The panelists reviewed current knowledge about the Omicron variant, emphasizing that while it appears to be more transmissible but has been suggested as possibly less virulent than previous variants, these observations are very preliminary and largely based on news reports and preprints. It is too early to know the degree to which people infected with Omicron will suffer adverse outcomes, including hospitalization, a need for mechanical ventilation, persisting symptoms, and death. They emphasized the importance of widespread vaccination both to reduce the adverse clinical impact of Omicron and other variants and to prevent the emergence of new variants.There was a robust discussion of the degree to which infection with SARS-CoV-2 protects against subsequent infection. Panelists agreed that infection surely boosted antibody levels, offering some immunity, but the protection was temporary. Vaccination after acute infection clearly augments immunity. Clinicians have many questions about why measuring antibody levels to assess the degree of people's level of immunity has not become recommended clinical practice. All 3 panelists dissuaded clinicians from measuring antibodies outside of research settings. Commercially available antibody assays are widely variable and questionable in their accuracy. Consequently, currently available tests are likely to misinform rather than inform. Yet, the hope is that in the future, tests such as those we use in clinical settings to assess immunity to other infectious diseases will become available. Unfortunately, we are not there yet.Outpatient therapies, monoclonal antibodies, and oral antivirals are important components of the clinical armamentarium necessary to move us from pandemic to endemic disease. The panelists shared concerns about the logistic challenges to timely and equitable administration of these therapies. They all agreed that timely and easily accessible COVID-19 testing at sites that are able to administer treatment to people who test positive was necessary to realize the benefit of existing and emerging therapeutics.Panelists emphasized the critical need to expand testing. Even if imperfect, rapid home tests can guide safe behavior as people resume activities, such as travel and gathering with others. The panelists shared experiences in using these tests themselves. They applauded U.S. government efforts to expand availability of COVID-19 tests but worried that the need to obtain reimbursement from insurers will create obstacles that lead to suboptimal and inequitable testing.Other topics addressed included vaccine side effects, persisting symptoms following acute COVID-19, use of ineffective and even harmful therapies, and emerging data that persons with immunocompromise may have difficulty clearing the virus after acute infection and remain at risk for transmitting infection outside of normal quarantine time frames. Panelists also reflected on whether the pandemic will increase or decrease the attractiveness of clinical specialties, such as infectious diseases.This program (Video) and previous ones (1–6) are available for viewing on Annals.org.Video. ACP/Annals COVID-19 Forum VII: Challenging Clinical Questions The ACP/Annals COVID-19 Forum VII, held on 8 December 2021, features speakers Jeanne Marrazzo, MD, MPH; Sabrina A. Assoumou, MD, MPH; Judith S. Currier, MD, MSc; and Deborah Cotton, MD, MPH. (Duration 1:24:34)References1. Laine C, Cotton D, Moyer DV. COVID-19 vaccine: what physicians need to know. Ann Intern Med. 2020;173:830. [PMID: 33074704] doi:10.7326/M20-6841 LinkGoogle Scholar2. Laine C, Cotton D, Moyer DV. COVID-19 vaccine: promoting vaccine acceptance. Ann Intern Med. 2021;174:252-253. [PMID: 33347321] doi:10.7326/M20-8008 LinkGoogle Scholar3. Laine C, Cotton D, Moyer DV. COVID-19 vaccine distribution and allocation: what physicians need to know. Ann Intern Med. 2021;174:413-414. [PMID: 33492990] doi:10.7326/M21-0331 LinkGoogle Scholar4. Laine C, Cotton D, Moyer DV. COVID-19 vaccine: practical clinical considerations. Ann Intern Med. 2021;174:694. [PMID: 33769829] doi:10.7326/M21-1260 LinkGoogle Scholar5. Laine C, Cotton D. COVID-19: evaluation and care of patients with persistent symptoms following acute SARS-CoV-2 infection. Ann Intern Med. 2021;174:1159-1160. [PMID: 34115532] doi:10.7326/M21-2342 LinkGoogle Scholar6. Laine C, Cotton D, Moyer DV. COVID-19: clinical and public health implications of SARS-CoV-2 immunology. Ann Intern Med. 2021;174:1733-1734. [PMID: 34633835] doi:10.7326/M21-3840 LinkGoogle Scholar Comments0 CommentsSign In to Submit A Comment Nelson R Zide, MDself13 December 2021 Antibiotics ve monoclonals When does one use antivirals (especially the new po variety) vs. monoclonals? And/or? Disclosures: Emerald Hills DR. SEIKH JAHANGIR ALAM, MBBS,PG.DIP.CARD(LONDON). FRCP (GLASG), FACP, FCCPConsultant Physician (Private Practice) Vill-Santipur, Post- Meched, Dist- Purba Medinipur, State- West Bengal, PIN-721137, INDIA15 December 2021 Do we need a new discovery beyond our conventional thinkings? Thanks a lot for this excellent article. As per my entire personal opinion we will be unsuccessful to invent definite antiviral medicines and vaccine against COVID-19 for permanent measures. Probably we need a new discovery beyond our conventional thinkings. I am optimistic for the best of mankind. Gaurav ChhayaShivam Medicare Clinic, Ahmedabad4 January 2022 New variant … with new issues.. It was a very clear message by panelist. My question is about newer variants emerging day by day, and their effects on patients' lives, what is the best strategy for avoiding such infection in life? Author, Article, and Disclosure InformationAffiliations: Editor in Chief, Annals of Internal Medicine Executive Vice President and Chief Executive Officer, American College of PhysiciansDeputy Editor, Annals of Internal Medicine Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M21-4611.Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Stephanie Chang, MD, MPH, Deputy Editor, reports employment with the Agency for Healthcare Research and Quality, travel compensation from the Guidelines International Network, and participation in the Patient-Centered Outcomes Research Institute methodology committee. Vineet Chopra, MD, MSc, Deputy Editor, reports grants received from the Agency for Healthcare Research and Quality and royalties from UpToDate and Oxford University Press. Deborah Cotton, MD, MPH, Deputy Editor, reports that she has no financial relationships or interests to disclose. Eliseo Guallar, MD, MPH, DrPH, Deputy Editor, Statistics, reports that he is employed at Johns Hopkins University. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center and consultancy with Boston Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports employment with the Perelman School of Medicine, University of Pennsylvania, and consultancies with the U.S. Food and Drug Administration and the State of Colorado.Corresponding Author: Christine Laine, MD, MPH, Editor in Chief, Annals of Internal Medicine, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, [email protected]org.This article was published at Annals.org on 14 December 2021. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoCOVID-19 Vaccine: What Physicians Need to Know Christine Laine , Deborah Cotton , and Darilyn V. Moyer COVID-19 Vaccine: Promoting Vaccine Acceptance Christine Laine , Deborah Cotton , and Darilyn V. Moyer COVID-19 Vaccine Distribution and Allocation: What Physicians Need to Know Christine Laine , Deborah Cotton , and Darilyn V. Moyer COVID-19 Vaccine: Practical Clinical Considerations Christine Laine , Deborah Cotton , and Darilyn V. Moyer COVID-19: Evaluation and Care of Patients With Persistent Symptoms Following Acute SARS-CoV-2 Infection Christine Laine and Deborah Cotton COVID-19: Clinical and Public Health Implications of SARS-CoV-2 Immunology Christine Laine , Deborah Cotton , and Darilyn V. Moyer Outpatient Evaluation and Management of COVID-19 Christine Laine , Deborah Cotton , and Darilyn V. Moyer Care of Patients With New, Continuing, or Recurring Symptoms After Acute SARS-CoV-2 Infection Christine Laine and Deborah Cotton Current Clinical Challenges in the Prevention and Management of COVID-19 Christine Laine and Deborah Cotton Metrics Cited byOutpatient Evaluation and Management of COVID-19Christine Laine, MD, MPH, Deborah Cotton, MD, MPH, Darilyn V. Moyer, MD February 2022Volume 175, Issue 2Page: 276-277KeywordsCOVID-19Infectious diseasesPrevention, policy, and public health ePublished: 14 December 2021 Issue Published: February 2022 Copyright & PermissionsCopyright © 2021 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...