Expert interview: Top questions patients are asking about COVID—and how to answer them

There's one thing we know for sure about COVID-19: This ever-changing virus continues to baffle clinicians, researchers, and patients alike.

As a medical provider, you’ve likely faced your fair share of questions from your own patients. With a continually evolving evidence base, providing clear answers can be tricky—and in many cases, there simply is no straight answer.  

On antiviral medications

Patients ask: Should I take antiviral medications to protect myself against COVID? I heard that the Biden administration is piloting the “Test-to-Treat” program, which will allow a pharmacist to give me antiviral medications right after a positive COVID test. Should I pursue this option?

Dr. Glatt: Antiviral medications should be taken only with a physician’s prescription. There are serious concerns about inappropriate administration of these medications based on various medical considerations. Antivirals are excellent medications when they work and there are no contraindications.

Some of them shouldn’t be taken by pregnant women or women who are planning pregnancy, or by individuals on certain medications. Only a knowledgeable physician or licensed practitioner should be making these decisions; I certainly don’t think that you should walk into a pharmacy and pick these up without a physician’s involvement.

On infections

Patients ask: Other people in my household are ill with COVID-19, but why am I not infected? And why are some people infected with COVID twice?

Dr. Glatt: The answer is that there are many, many variables. We don’t have the ability to say why one person will or will not get infected.

You can’t definitively answer every single question about COVID-19, such as, “Why do some people get infected? Why do some people have more severe infection?” We sometimes don’t have a full understanding. We have generalizations, but we don’t have all the facts.

There are also different variants of the virus. Plus, as mentioned, some of it we just don’t fully understand. Why doesn’t the immune system protect fully? It clearly doesn’t, although it does provide significant protection in many patients. It’s important to realize that people who have had COVID are at much lower risk of getting COVID again, and this risk can be decreased further with vaccination.

Patients ask: I had the COVID-19 vaccine, but I still developed a breakthrough infection. How can this be?

Dr. Glatt: That’s a misunderstanding about how the disease and vaccines work. If COVID-19 is going to infect someone with a superficial nose/upper airway infection, the vaccine won’t necessarily have the ability to protect that person. But the vaccine will tremendously protect the person from systemic illness and from getting really sick.

That’s really the efficacy of the vaccine—which is not reflected by the number of people who get infected, but by the number of people who do not die, who do not get hospitalized, who do not run into serious problems with COVID, and who do not get “long COVID.”

On being immunocompromised

Patient ask: Why am I on the immunocompromised list?

Dr. Glatt: It’s important for physicians to know what types of chronic conditions potentially place patients at higher risk. Patients at higher risk should be cared for differently from patients at lower risks.

The risks aren’t always absolute or clear-cut, but the CDC has provided some guidance.^[] It’s important to identify patients whose conditions place them in the immunocompromised category, as they may benefit from an additional dose of vaccine or prophylactic measures. Fortunately, the vast majority of people aren’t on those lists.

On mask guidelines

Patients ask: I’m confused by what the CDC says about masks. Should I be wearing them? 

Dr. Glatt: There is no simple answer when it comes to masks. For different patients and scenarios, there will be different answers. Some patients can be advised to wear masks, whereas in the same country and region, other patients may not be advised to wear masks. It depends on the incidence of COVID, your vaccine status, the underlying medical problems, and who else in the house is at risk.

All those factors go into deciding whether to mask. Outdoors, you don’t need to mask, and indoors, it depends on who you’re with. If it’s just your immediate family or individuals whom you know are vaccinated, it may be reasonable to not mask. In other situations, where you don’t know who you are with, or it’s a packed indoor area with poor ventilation, it may be smart to mask—especially for those who haven’t had COVID recently and have risk factors.

On vaccination

Patients ask: Should I get vaccinated if I get COVID? And do I need a second booster?

Dr. Glatt: Yes, it still will give you benefit. Studies show that people who have COVID and got vaccinated are better protected than people who have only been infected with COVID or only got vaccinated. The combination of infection and vaccination will be beneficial.

For a small population who are moderately or severely immunocompromised, a fourth dose is potentially appropriate. But, for the rest of the population, there are no indications for a fourth dose at this time. What will the future bring? We will have to wait for the data to be published before we can make a definitive statement about additional boosters.