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Tag: long COVID

  • ‘If Exercise Could Cure This, I Would Have Been Cured So Quickly’

    ‘If Exercise Could Cure This, I Would Have Been Cured So Quickly’

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    In the weeks after she caught COVID, in May 2022, Lauren Shoemaker couldn’t wait to return to her usual routine of skiing, backpacking, and pregaming her family’s eight-mile hikes with three-mile jogs. All went fine in the first few weeks after her infection. Then, in July, hours after finishing a hike, Shoemaker started to feel off; two days later, she couldn’t make it to the refrigerator without feeling utterly exhausted. Sure it was a fluke, she tried to hike again—and this time, was out of commission for months. Shoemaker, an ecologist at the University of Wyoming, couldn’t do her alpine fieldwork; she struggled to follow a movie with a complex plot. She was baffled. Exercise, the very thing that had reliably energized her before, had suddenly become a trigger for decline.

    For the majority of people, exercise is scientifically, physiologically, psychologically good. It boosts immunity, heart function, cognition, mood, energy, even life span. Doctors routinely prescribe it to patients recovering from chronic obstructive pulmonary disease and heart attacks, managing metabolic disease, or hoping to stave off cognitive decline. Conditions that worsen when people strive for fitness are very rare. Post-exertional malaise (PEM), which affects Shoemaker and most other people with long COVID, just happens to be one of them.

    PEM, first described decades ago as a hallmark of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), is now understood to fundamentally alter the body’s ability to generate and use energy. For people with PEM, just about any form of physical, mental, or emotional exertion—in some cases, activities no more intense than answering emails, folding laundry, or digesting a particularly rare steak—can spark a debilitating wave of symptoms called a crash that may take weeks or months to abate. Simply sitting upright for too long can leave Letícia Soares, a long-hauler living in Brazil, temporarily bedbound. When she recently moved into a new home, she told me, she didn’t bother buying a dining table or chairs—“it just felt useless.”

    Read: How much less to worry about long COVID now

    When it comes to PEM, intense exercise—designed to boost fitness—is “absolutely contraindicated,” David Putrino, a physical therapist who runs a long-COVID clinic at Mount Sinai, in New York, told me. And yet, the idea that exertion could undo a person rather than returning them to health is so counterintuitive that some clinicians and researchers still endorse its potential benefits for those with PEM; it’s dogma that Shoemaker heard repeatedly after she first fell ill. “If exercise could cure this,” she told me, “I would have been cured so quickly.”

    The problem is, there’s no consensus about what people who have PEM should do instead. Backing off physical activity too much might start its own downward spiral, as people lose muscle mass and strength in a phenomenon called deconditioning. Navigating the middle ground between deconditioning and crashing is “where the struggle begins,” Denyse Lutchmansingh, a pulmonary specialist at Yale, told me. And as health experts debate which side to err on, millions of long-haulers are trying to strike their own balance.

    Though it’s now widely accepted that PEM rejiggers the body’s capacity for strain, scientists still aren’t sure of the precise biological causes. Some studies have found evidence of impaired blood flow, stymieing the delivery of oxygen to cells; others have discovered broken mitochondria struggling to process raw fuel into power. A few have seen hints of excessive inflammation, and immune cells aberrantly attacking muscles; others point to issues with recovery, perhaps via a slowdown in the clearance of lactate and other metabolic debris.

    The nature of the crashes that follow exertion can be varied, sprawling, and strange. They might appear hours or days after a catalyst. They can involve flu-like coughs or sore throats. They may crater a patient’s cognitive capacity or plague them with insomnia for weeks; they can leave people feeling so fatigued and pained, they’re almost unable to move. Some of Shoemaker’s toughest crashes have saddled her with tinnitus, numbness, and extreme sensitivity to sound and light. Triggers can also change over time; so can people’s symptoms—even the length of the delay before a crash.

    But perhaps the worst part is what an accumulation of crashes can do. Rob Wüst, who studies skeletal-muscle physiology at Amsterdam University Medical Center, told me that his team has found an unusual amount of muscle damage after exertion in people with PEM that may take months to heal. People who keep pushing themselves past their limit could watch their baseline for exertion drop, and then drop again. “Every time you PEM yourself, you travel a little further down the rabbit hole,” Betsy Keller, an exercise physiologist at Ithaca College, told me.

    Read: Long COVID has forced a reckoning for one of medicine’s most neglected diseases

    Still, the goal of managing PEM has never been to “just lay in a bed all day and don’t do anything,” Lily Chu, the vice president of the International Association for Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (IACFS/ME), told me. In the 1960s, a group of scientists found that three weeks of bed rest slashed healthy young men’s capacity for exertion by nearly 30 percent. (The participants eventually trained themselves back to baseline.) Long periods of bed rest were once commonly prescribed for recovery from heart attacks, says Prashant Rao, a sports cardiologist at Beth Israel Deaconess Medical Center, in Massachusetts. But now too much rest is actively avoided, because “there’s a real risk of spiraling down, and symptoms worsening,” Rao told me. “I really fear for that, even for people with PEM.”

    There is no rulebook for threading this needle, which has led researchers to approach treatments and rehabilitation for long COVID in different ways. Some clinical trials that involve exercise as an intervention explicitly exclude people with PEM. “We did not feel like the exercise program we designed would be safe for those individuals,” Johanna Sick, a physiologist at the University of Vienna who is helping run one such trial, told me.

    Other researchers hold out hope that activity-based interventions may still help long-haulers, and are keeping patients with PEM in experiments. But some of those decisions have been controversial. The government-sponsored RECOVER trial was heavily criticized last year for its plan to enroll long-haulers in an exercise study. Scientists have since revised the trial’s design to reroute participants with moderate to severe PEM to another intervention, according to Adrian Hernandez, the Duke cardiologist leading the trial. The details are still being finalized, but the plan is to instead look at pacing, a strategy for monitoring activity levels to ensure that people stay below their crash threshold, Janna Friedly, a physiatrist at the University of Washington who’s involved in the trial, told me.

    Certain experimental regimens can be light enough—stretching, recumbent exercises—to be tolerable by many (though not all) people with PEM. Some researchers are trying to monitor participants’ heart rate, and having them perform only activities that keep them in a low-intensity zone. But even when patients’ limitations are taken into account, crashes can be hard to avoid, Tania Janaudis-Ferreira, a physiotherapist at McGill University, in Quebec, told me. She recently wrapped a clinical trial in which, despite tailoring the regimen to each individual, her team still documented several mild to moderate crashes among participants with PEM.

    Read: Long COVID is being erased—again

    Just how worrisome crashes are is another matter of contention. Pavlos Bobos, a musculoskeletal-health researcher at the University of Western Ontario, told me that he’d like to see more evidence of harm before ruling out exercise for long COVID and PEM. Bruno Gualano, a physiologist at the University of São Paulo, told me that even though crashes seem temporarily damaging, he’s not convinced that exercise worsens PEM in the long term. But Putrino, of Mount Sinai, is adamant that crashes set people back; most other experts I spoke with agreed. And several researchers told me that, because PEM seems to upend basic physiology, reduced activity may not be as worrisome for people with the condition as it is for those without.

    For Shoemaker, the calculus is clear. “Coming back from being deconditioned is honestly trivial compared to recovering from PEM,” she told me. She’s willing to wait for evidence-based therapies that can safely improve her PEM. “Whatever we figure out, if I could get healthy,” she told me, “then I can get back in shape.”

    At this point, several patients and researchers told me, most exercise-based trials for long COVID seem to be at best a waste of resources, and at worst a recipe for further harm. PEM is not new, nor are the interventions being tested. Decades of research on ME/CFS have already shown that traditional exercise therapy harms more often than it helps. (Some researchers insisted that more PEM studies are needed in long-haulers—just in case the condition diverges substantially from its manifestation in ME/CFS.) And although a subset of long-haulers could be helped by exercise, experts don’t yet have a great way to safely distinguish them from the rest.

    Even pacing, although often recommended for symptom management, is not generally considered to be a reliable treatment, which is where most long-COVID patient advocates say funds should be focused. Ideally, Putrino and others told me, resources should be diverted to trials investigating drugs that might address PEM’s roots, such as the antiviral Paxlovid, which could clear lingering virus from long-haulers’ tissues. Some researchers are also hopeful about pyridostigmine, a medication that might enhance the delivery of oxygen to tissues, as well as certain supplements that might support mitochondria on the fritz.

    Those interventions are still experimental—and Putrino said that no single one is likely to work for everyone. That only adds to the challenge of studying PEM, which has been shrouded in disbelief for decades. Despite years of research on ME/CFS, Chu, of the IACFS/ME, told me that many people with the condition have encountered medical professionals who suggest that they’re just anxious, even lazy. It doesn’t help that there’s not yet a blood test for PEM; to diagnose it, doctors must ask their patients questions and trust the answers. Just two decades ago, researchers and physicians speculated that PEM stemmed from an irrational fear of activity; some routinely prescribed therapy, antidepressants, and just pushing through, Chu said. One highly publicized 2011 study, since widely criticized as shoddy science, appeared to support those claims—influencing treatment recommendations from top health authorities such as the CDC.

    The CDC and other organizations have since reversed their position on exercise and cognitive behavioral therapy as PEM treatments. Even so, many people with long COVID and ME/CFS are still routinely told to blow past their limits. All of the long-haulers I spoke with have encountered this advice, and learned to ignore it. Fighting those calls to exercise can be exhausting in its own right. As Ed Yong wrote in The Atlantic last year, American society has long stigmatized people who don’t push their way through adversity—even if that adversity is a medically documented condition that cannot be pushed through. Reconceptualizing the role of exercise in daily living is already a challenge; it is made all the more difficult when being productive—even overworked—is prized above all else.

    Read: Fatigue can shatter a person

    Long-haulers know that tension intimately; some have had to battle it within themselves. When Julia Moore Vogel, a researcher at Scripps, developed long COVID in the summer of 2020, she was at first determined to grit her way through. She took up pilates and strength training, workouts she at the time considered gentle. But the results were always the same: horrific migraines that relegated her to bed. She now does physical therapy to keep herself moving in safe and supervised amounts. When Vogel, a former competitive runner, started her program, she was taken aback by how little she was asked to do—sometimes just two reps of chin tucks. “I would always laugh because I would be like, ‘These are not exercises,’” she told me. “I’ve had to change my whole mental model about what exercise is, what exertion is.”

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    Katherine J. Wu

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  • How Much Less to Worry About Long COVID Now

    How Much Less to Worry About Long COVID Now

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    Compared with the worst days of the pandemic—when vaccines and antivirals were nonexistent or scarce, when more than 10,000 people around the world were dying each day, when long COVID largely went unacknowledged even as countless people fell chronically ill—the prognosis for the average infection with this coronavirus has clearly improved.

    In the past four years, the likelihood of severe COVID has massively dropped. Even now, as the United States barrels through what may be its second-largest wave of SARS-CoV-2 infections, rates of death remain near their all-time low. And although tens of thousands of Americans are still being hospitalized with COVID each week, emergency rooms and intensive-care units are no longer routinely being forced into crisis mode. Long COVID, too, appears to be a less common outcome of new infections than it once was.

    Read: The future of long COVID

    But where the drop in severe-COVID incidence is clear and prominent, the drop in long-COVID cases is neither as certain nor as significant. Plenty of new cases of the chronic condition are still appearing with each passing wave—even as millions of people who developed it in years past continue to suffer its long-term effects.

    In a way, the shrinking of severe disease has made long COVID’s dangers more stark: Nowadays, “long COVID to me still feels like the biggest risk for most people,” Matt Durstenfeld, a cardiologist at UC San Francisco, told me—in part because it does not spare the young and healthy as readily as severe disease does. Acute disease, by definition, eventually comes to a close; as a chronic condition, long COVID means debilitation that, for many people, may never fully end. And that lingering burden, more than any other, may come to define what living with this virus long term will cost.

    Most of the experts I spoke with for this story do think that the average SARS-CoV-2 infection is less likely to unfurl into long COVID than it once was. Several studies and data sets support this idea; physicians running clinics told me that, anecdotally, they’re seeing that pattern play out among their patient rosters too. The number of referrals coming into Alexandra Yonts’s long-COVID clinic at Children’s National, in Washington, D.C., for instance, has been steadily dropping in the past year, and the waitlist to be seen has shortened. The situation is similar, other experts told me, among adult patients at Yale and UCSF. Lisa Sanders, an internal-medicine physician who runs a clinic at Yale, told me that more recent cases of long COVID appear to be less debilitating than ones that manifested in 2020. “People who got the earliest versions definitely got whacked the worst,” she said.

    That’s reflective of how our relationship to COVID has changed overall. In the same way that immunity can guard a body against COVID’s most severe, acute forms, it may also protect against certain kinds of long COVID. (Most experts consider long COVID to be an umbrella term for many related but separate syndromes.) Once wised up to a virus, our defenses become strong and fast-acting, more able to keep infection from spreading and lingering, as it might in some long-COVID cases. Courses of illness also tend to end more quickly, with less viral buildup, giving the immune system less time or reason to launch a campaign of friendly fire on other tissues, another potential trigger of chronic disease.

    In line with that logic, a glut of studies has shown that vaccination—especially recent and repeated vaccination—can reduce a person’s chances of developing long COVID. “There is near universal agreement on that,” Ziyad Al-Aly, an epidemiologist and a clinician at Washington University in St. Louis, told me. Some experts think that antiviral use may be making a dent as well, by decreasing the proportion of COVID cases that progress to severe disease, a risk factor for certain types of long COVID. Others have pointed to the possibility that more recent variants of the virus—some of them maybe less likely to penetrate deeply into the lungs or affect certain especially susceptible organs—may be less apt to trigger chronic illness too.

    But consensus on any of these points is lacking—especially on just how much, if at all, these interventions help. Experts are divided even on the effect of vaccines, which have the most evidence to back their protective punch: Some studies find that they trim risk by 15 percent, others up to about 70 percent. Paxlovid, too, has become a point of contention: While some analyses have shown that taking the antiviral early in infection helps prevent long COVID, others have found no effect at all. Any implication that we’ve tamed long COVID exaggerates how positive the overall picture is. Hannah Davis, one of the leaders of the Patient-Led Research Collaborative, who developed long COVID during the pandemic’s first months, told me that she’s seen how the most optimistic studies get the most attention from the media and the public. With a topic as unwieldy and challenging to understand as this, Davis said, “we still see overreactions to good news, and underreactions to bad news.”

    That findings are all over the place on long COVID isn’t a shock. The condition still lacks a universal definition or a standard method of diagnosis; when recruiting patients into their studies, research groups can rely on distinct sets of criteria, inevitably yielding disparate and seemingly contradictory sets of results. With vaccines, for instance, the more wide-ranging the set of potential long-COVID symptoms a study looks at, the less effective shots may appear—simply because “vaccines don’t work on everything,” Al-Aly told me.

    Studying long COVID has also gotten tougher. The less attention there is on COVID, “the less likely people are to associate long-term symptoms with it,” Priya Duggal, an infectious-disease epidemiologist at Johns Hopkins University, told me. Fewer people are testing for the virus. And some physicians still “don’t believe in long COVID—that’s what I hear a lot,” Sanders told me. The fact that fewer new long-COVID cases are appearing before researchers and clinicians could be in part driven by fewer diagnoses being made. Al-Aly worries that the situation could deteriorate further: Although long-COVID research is still chugging along, “momentum has stalled.” Others share his concern. Continued public disinterest, Duggal told me, could dissuade journals from publishing high-profile papers on the subject—or deter politicians from setting aside funds for future research.

    Even if new cases of long COVID are less likely nowadays, the incidence rates haven’t dropped to zero. And rates of recovery are slow, low, and still murky. At this point, “people are entering this category at a greater rate than people are exiting this category,” Michael Peluso, a long-COVID researcher at UCSF, told me. The CDC’s Household Pulse Survey, for instance, shows that the proportion of American adults reporting that they’re currently dealing with long COVID has held steady—about 5 to 6 percent—for more than a year (though the numbers have dropped since 2021). Long COVID remains one of the most debilitating chronic conditions in today’s world—and full recovery remains uncommon, especially, it seems, for those who have been dealing with the disease for the longest.

    Exact numbers on recovery are tricky to come by, for the same reasons that it’s difficult to pin down how effective preventives are. Some studies report rates far more optimistic than others. David Putrino, a physical therapist who runs a long-COVID clinic at Mount Sinai Health System, where he and his colleagues have seen more than 3,000 long-haulers since the pandemic’s start, told me his best estimates err on the side of the prognosis being poor. About 20 percent of Putrino’s patients fully recover within the first few months, he told me. Beyond that, though, he routinely encounters people who experience only partial symptom relief—as well as a cohort that, “no matter what we think to try,” Putrino told me, “we can’t even seem to stop them from deteriorating.” Reports of higher recovery rates, Putrino and other experts said, might be conflating improvement with a return to baseline, or mistakenly assuming that people who stop responding to follow-ups are better, rather than just done participating.

    Read: Long COVID is being erased—again

    Davis also worries that recovery rates could drop. Some researchers and clinicians have noticed that today’s new long-COVID patients are more likely than earlier patients to come in with certain neurological symptoms—among them, brain fog and dizziness—that have been linked to slower recovery trajectories, Lekshmi Santhosh, a pulmonary specialist at UCSF, told me.

    In any case, recovery rates are still modest enough that long-COVID clinics across the country—even ones that have noted a dip in demand—remain very full. Currently, Putrino’s clinic has a waitlist of three to six months. The same is true for clinical trials investigating potential treatments. One, run by Peluso, that is investigating monoclonal-antibody therapy has a waitlist that is “hundreds of people deep,” Peluso told me: “We do not have the problem of not being able to find people who want to participate.”

    Any decrease in long-COVID incidence may not last, either. Viral evolution could always produce a new variant or subvariant with higher risks of chronic issues. The protective effects of vaccination may also be quite temporary, and the fewer people who keep up to date with their shots, the more porous immunity’s safety net may become. In this way, kids—though seemingly less likely to develop long COVID overall—may remain worryingly vulnerable, Yonts told me, because they’re born entirely susceptible, and immunization rates in the youngest age groups remain extremely low. And yet, little kids who get long COVID may need to live with it the longest. Some of Yonts’s patients have barely started grade school and have already been sick for three-plus years—half of their lives so far, or more.

    Long COVID can also manifest after repeat infections of SARS-CoV-2—and although several experts told me they think that each subsequent exposure poses less incremental risk, any additional exposure is worrisome. People all over the world are being exposed, over and over again, as the pathogen spreads with blistering speed, more or less year-round, in populations that have mostly dropped mitigations and are mostly behind on annual shots (where they’re available). Additional infections can worsen the symptoms of people living with long COVID, or yank them out of remission. Long COVID’s inequities may also widen as marginalized populations, less likely to receive vaccines or antivirals and more likely to be exposed to the virus, continue to develop the condition at higher rates.

    There’s no question that COVID-19 has changed. The disease is more familiar; the threat of severe disease, although certainly not vanished, is quantitatively less now. But dismissing the dangers of the virus would be a mistake. Even if rates of new long-COVID cases continue to drop for some time, Yonts pointed out, they will likely stabilize somewhere. These risks will continue to haunt us and incur costs that will keep adding up. Long COVID may not kill as directly as severe, acute COVID has. But people’s lives still depend on avoiding it, Putrino told me—“at least, their life as they know it right now.”

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    Katherine J. Wu

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  • Sick Season Will Be Worse From Now On

    Sick Season Will Be Worse From Now On

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    Last fall, when RSV and flu came roaring back from a prolonged and erratic hiatus, and COVID was still killing thousands of Americans each week, many of the United States’ leading infectious-disease experts offered the nation a glimmer of hope. The overwhelm, they predicted, was probably temporary—viruses making up ground they’d lost during the worst of the pandemic. Next year would be better.

    And so far, this year has been better. Some of the most prominent and best-tracked viruses, at least, are behaving less aberrantly than they did the previous autumn. Although neither RSV nor flu is shaping up to be particularly mild this year, says Caitlin Rivers, an epidemiologist at the Johns Hopkins Center for Health Security, both appear to be behaving more within their normal bounds.

    But infections are still nowhere near back to their pre-pandemic norm. They never will be again. Adding another disease—COVID—to winter’s repertoire has meant exactly that: adding another disease, and a pretty horrific one at that, to winter’s repertoire. “The probability that someone gets sick over the course of the winter is now increased,” Rivers told me, “because there is yet another germ to encounter.” The math is simple, even mind-numbingly obvious—a pathogenic n+1 that epidemiologists have seen coming since the pandemic’s earliest days. Now we’re living that reality, and its consequences. “What I’ve told family or friends is, ‘Odds are, people are going to get sick this year,’” Saskia Popescu, an epidemiologist at the University of Maryland School of Medicine, told me.

    Even before the pandemic, winter was a dreaded slog—“the most challenging time for a hospital” in any given year, Popescu said. In typical years, flu hospitalizes an estimated 140,000 to 710,000 people in the United States alone; some years, RSV can add on some 200,000 more. “Our baseline has never been great,” Yvonne Maldonado, a pediatrician at Stanford, told me. “Tens of thousands of people die every year.” In “light” seasons, too, the pileup exacts a tax: In addition to weathering the influx of patients, health-care workers themselves fall sick, straining capacity as demand for care rises. And this time of year, on top of RSV, flu, and COVID, we also have to contend with a maelstrom of other airway viruses—among them, rhinoviruses, parainfluenza viruses, human metapneumovirus, and common-cold coronaviruses. (A small handful of bacteria can cause nasty respiratory illnesses too.) Illnesses not severe enough to land someone in the hospital could still leave them stuck at home for days or weeks on end, recovering or caring for sick kids—or shuffling back to work, still sick and probably contagious, because they can’t afford to take time off.

    To toss any additional respiratory virus into that mess is burdensome; for that virus to be SARS-CoV-2 ups the ante all the more. “This is a more serious pathogen that is also more infectious,” Ajay Sethi, an epidemiologist at the University of Wisconsin at Madison, told me. This year, COVID-19 has so far killed some 80,000 Americans—a lighter toll than in the three years prior, but one that still dwarfs that of the worst flu seasons in the past decade. Globally, the only infectious killer that rivals it in annual-death count is tuberculosis. And last year, a CDC survey found that more than 3 percent of American adults were suffering from long COVID—millions of people in the United States alone.

    Read: Is COVID a common cold yet?

    With only a few years of data to go on, and COVID-data tracking now spotty at best, it’s hard to quantify just how much worse winters might be from now on. But experts told me they’re keeping an eye on some potentially concerning trends. We’re still rather early in the typical sickness season, but influenza-like illnesses, a catchall tracked by the CDC, have already been on an upward push for weeks. Rivers also pointed to CDC data that track trends in deaths caused by pneumonia, flu, and COVID-19. Even when SARS-CoV-2 has been at its most muted, Rivers said, more people have been dying—especially during the cooler months—than they were at the pre-pandemic baseline. The math of exposure is, again, simple: The more pathogens you encounter, the more likely you are to get sick.

    A larger roster of microbes might also extend the portion of the year when people can expect to fall ill, Rivers told me. Before the pandemic, RSV and flu would usually start to bump up sometime in the fall, before peaking in the winter; if the past few years are any indication, COVID could now surge in the summer, shading into RSV’s autumn rise, before adding to flu’s winter burden, potentially dragging the misery out into spring. “Based on what I know right now, I am considering the season to be longer,” Rivers said.

    With COVID still quite new, the exact specifics of respiratory-virus season will probably continue to change for a good while yet. The population, after all, is still racking up initial encounters with this new coronavirus, and with regularly administered vaccines. Bill Hanage, an epidemiologist at Harvard’s T. H. Chan School of Public Health, told me he suspects that, barring further gargantuan leaps in viral evolution, the disease will continue to slowly mellow out in severity as our collective defenses build; the virus may also pose less of a transmission risk as the period during which people are infectious contracts. But even if the dangers of COVID-19 are lilting toward an asymptote, experts still can’t say for sure where that asymptote might be relative to other diseases such as the flu—or how long it might take for the population to get there. And no matter how much this disease softens, it seems extraordinarily unlikely to ever disappear. For the foreseeable future, “pretty much all years going forward are going to be worse than what we’ve been used to before,” Hanage told me.

    Read: The next stage of COVID is starting now

    In one sense, this was always where we were going to end up. SARS-CoV-2 spread too quickly and too far to be quashed; it’s now here to stay. If the arithmetic of more pathogens is straightforward, our reaction to that addition could have been too: More disease risk means ratcheting up concern and response. But although a core contingent of Americans might still be more cautious than they were before the pandemic’s start—masking in public, testing before gathering, minding indoor air quality, avoiding others whenever they’re feeling sick—much of the country has readily returned to the pre-COVID mindset.

    When I asked Hanage what precautions worthy of a respiratory disease with a death count roughly twice that of flu’s would look like, he rattled off a familiar list: better access to and uptake of vaccines and antivirals, with the vulnerable prioritized; improved surveillance systems to offer  people at high risk a better sense of local-transmission trends; improved access to tests and paid sick leave. Without those changes, excess disease and death will continue, and “we’re saying we’re going to absorb that into our daily lives,” he said.

    And that is what is happening. This year, for the first time, millions of Americans have access to three lifesaving respiratory-virus vaccines, against flu, COVID, and RSV. Uptake for all three remains sleepy and halting; even the flu shot, the most established, is not performing above its pre-pandemic baseline. “We get used to people getting sick every year,” Maldonado told me. “We get used to things we could probably fix.” The years since COVID arrived set a horrific precedent of death and disease; after that, this season of n+1 sickness might feel like a reprieve. But compare it with a pre-COVID world, and it looks objectively worse. We’re heading toward a new baseline, but it will still have quite a bit in common with the old one: We’re likely to accept it, and all of its horrors, as a matter of course.

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    Katherine J. Wu

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  • The Big COVID Question for Hospitals This Fall

    The Big COVID Question for Hospitals This Fall

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    Back in the spring, around the end of the COVID-19 public-health emergency, hospitals around the country underwent a change in dress code. The masks that staff had been wearing at work for more than three years vanished, in some places overnight. At UChicago Medicine, where masking policies softened at the end of May, Emily Landon, the executive medical director of infection prevention and control, fielded hate mail from colleagues, some chiding her for waiting too long to lift the requirement, others accusing her of imperiling the immunocompromised. At Vanderbilt University Medical Center, which did away with masking in April, ahead of many institutions, Tom Talbot, the chief hospital epidemiologist, was inundated with thank-yous. “People were ready; they were tired,” he told me. “They’d been asking for several months before that, ‘Can we not stop?’”

    But across hospitals and policies, infection-prevention experts shared one sentiment: They felt almost certain that the masks would need to return, likely by the end of the calendar year. The big question was exactly when.

    For some hospitals, the answer is now. In recent weeks, as COVID-19 hospitalizations have been rising nationwide, stricter masking requirements have returned to a smattering of hospitals in Massachusetts, California, and New York. But what’s happening around the country is hardly uniform. The coming respiratory-virus season will be the country’s first after the end of the public-health emergency—its first, since the arrival of COVID, without crisis-caliber funding set aside, routine tracking of community spread, and health-care precautions already in place. After years of fighting COVID in concert, hospitals are back to going it alone.

    A return to masking has a clear logic in hospitals. Sick patients come into close contact; medical procedures produce aerosols. “It’s a perfect storm for potential transmission of microbes,” Costi David Sifri, the director of hospital epidemiology at UVA Health, told me. Hospitals are on the front lines of disease response: They, more than nearly any other place, must prioritize protecting society’s vulnerable. And with one more deadly respiratory virus now in winter’s repertoire, precautions should logically increase in lockstep. But “there is no clear answer on how to do this right,” says Cameron Wolfe, an infectious-disease physician at Duke. Americans have already staked out their stances on masks, and now hospitals have to operate within those confines.

    When hospitals moved away from masking this spring, they each did so at their own pace—and settled on very different baselines. Like many other hospitals in Massachusetts, Brigham and Women’s Hospital dropped its mask mandate on May 12, the day the public-health emergency expired; “it was a noticeable difference, just walking around the hospital” that day, Meghan Baker, a hospital epidemiologist for both Brigham and Women’s Hospital and Dana-Farber Cancer Institute, told me. UVA Health, meanwhile, weaned staff off of universal masking over the course of about 10 weeks.

    Most masks at the Brigham are now donned on only a case-by-case basis: when a patient has active respiratory symptoms, say, or when a health-care worker has been recently sick or exposed to the coronavirus. Staff also still mask around the same subset of vulnerable patients that received extra protection before the pandemic, including bone-marrow-transplant patients and others who are highly immunocompromised, says Chanu Rhee, an associate hospital epidemiologist at Brigham and Women’s Hospital. UVA Health, meanwhile, is requiring masks for everyone in the hospital’s highest-risk areas—among them, certain intensive-care units, as well as cancer, transplant, and infusion wards. And although Brigham patients can always request that their providers mask, at UVA, all patients are asked upon admission whether they’d like hospital staff to mask.

    Nearly every expert I spoke with told me they expected that masks would at some point come back. But unlike the early days of the pandemic, “there is basically no guidance from the top now,” Saskia Popescu, an epidemiologist and infection-prevention expert at the University of Maryland School of Medicine, said. The CDC still has a webpage with advice on when to mask. Those recommendations are tailored to the general public, though—and don’t advise covering up until COVID hospital admissions go “way high, when the horse has well and truly left the barn,” Landon, at UChicago, told me. “In health care, we need to do something before that”—tamping down transmission prior to wards filling up.

    More specific advice could still emerge from the CDC, or individual state health departments. But going forward, the assumption is that “each hospital is supposed to have its own general plan,” Rhee told me. (I reached out to the CDC repeatedly about whether it might update its infection-prevention-guidance webpage for COVID—last retooled in May—but didn’t receive a response.)

    Which leaves hospitals with one of two possible paths. They could schedule a start to masking season, based on when they estimate cases might rise—or they could react to data as they come in, tying masking policies to transmission bumps. With SARS-CoV-2 still so unpredictable, many hospitals are opting for the latter. That also means defining a true case rise—“what I think everybody is struggling with right now,” Rhee said. There is no universal definition, still, for what constitutes a surge. And with more immunity layered over the population, fewer infections are resulting in severe disease and death—even, to a limited extent, long COVID—making numbers that might have triggered mitigations just a year or two ago now less urgent catalysts.

    Read: The future of long COVID

    Further clouding the forecast is the fact that much of the data that experts once relied on to monitor COVID in the community have faded away. In most parts of the country, COVID cases are no longer regularly tallied; people are either not testing, or testing only at home. Wastewater surveillance and systems that track all influenza-like illnesses could provide some support. But that’s not a whole lot to go on, especially in parts of the country such as Tennessee, where sewage isn’t as closely tracked, Tom Talbot, of Vanderbilt, told me.

    Some hospitals have turned instead to in-house stats. At Duke—which has adopted a mitigation policy that’s very similar to UVA’s—Wolfe has mulled pulling the more-masking lever when respiratory viruses account for 2 to 4 percent of emergency and urgent-care visits; at UVA, Sifri has considered taking action once 1 or 2 percent of employees call out sick, with the aim of staunching sickness and preserving staff. “It really doesn’t take much to have an impact on our ability to maintain operations,” Sifri told me. But “I don’t know if those are the right numbers.” Plus, internal metrics are now tricky for the same reasons they’ve gotten shaky elsewhere, says Xiaoyan Song, the chief infection-control officer at Children’s National Hospital, in Washington, D.C. Screening is no longer routine for patients, skewing positivity stats; even sniffly health-care workers, several experts told me, are now less eager to test and report.

    Read: What COVID hospitalization numbers are missing

    For hospitals that have maintained a more masky baseline, scenarios in which universal masking returns are a little easier to envision and enact. At UChicago Medicine, Landon and her colleagues have developed a color-coded system that begins at teal—masking for high-risk patients, patients who request masked care, and anyone with symptoms, plus masking in high-risk areas—and goes through everyone-mask-up-everywhere red; their team plans to meet weekly to assess the situation, based on a variety of community and internal metrics, and march their masking up or down. Wolfe, of Duke, told me that his hospital “wanted to reserve a little bit of extra masking quite intentionally,” so that any shift back toward stricter standards would feel like less of a shock: Habits are hard to break and then reform.

    Other hospitals that have been living mostly maskless for months, though, have a longer road back to universal masking, and staff members who might not be game for the trek. Should masks need to return at the Brigham or Dana-Farber, for instance, “I suspect the reaction will be mixed,” Baker told me. “So we really are trying to be judicious.” The hospital might try to preserve some maskless zones in offices and waiting rooms, for instance, or lower-risk rooms. And at Children’s National, which has also largely done away with masks, Song plans to follow the local health department’s lead. “Once D.C. Health requires hospitals to reimplement the universal-masking policy,” she told me, “we will be implementing it too.”

    Other mitigations are on the table. Several hospital epidemiologists told me they expected to reimplement some degree of asymptomatic screening for various viruses around the same time they reinstate masks. But measures such as visiting restrictions are a tougher call. Wolfe is reluctant to pull that lever before he absolutely has to: Going through a hospital stay alone is one of the “harder things for patients to endure.”

    A bespoke approach to hospital masking isn’t impractical. COVID waves won’t happen synchronously across communities, and so perhaps neither should policies. But hospitals that lack the resources to keep tabs on viral spread will likely be at a disadvantage, and Popescu told me she worries that “we’re going to see significant transmission” in the very institutions least equipped to handle such influx. Even the best-resourced places may hit stumbling blocks: Many are still reeling from three-plus years of crisis and are dealing with nursing shortages and worker burnout.

    Coordination hasn’t entirely gone away. In North Carolina, Duke is working with the University of North Carolina at Chapel Hill and North Carolina State University to shift policies in tandem; in Washington State, several regional health-care organizations have pledged to align their masking policies. And the Veterans Health Administration—where masking remains required in high-risk units—has developed a playbook for augmenting mitigations across its many facilities, which together make up the country’s largest integrated health-care system, says Shereef Elnahal, the undersecretary of Veterans Affairs for health. Still, institutions can struggle to move in sync: Attitudes on masking aren’t exactly universal across health-care providers, even within a hospital.

    The country’s experience with COVID has made hospitals that much more attuned to the impacts of infectious disease. Before the pandemic began, Talbot said, masking was a rarity in his hospital, even around high-risk patients; many employees would go on shifts sick. “We were pretty complacent about influenza,” he told me. “People could come to work and spread it.” Now hospital workers hold themselves to a stricter standard. At the same time, they have become intimately attuned to the drawbacks of constant masking: Some have complained that masks interfere with communication, especially for patients who are young or hard of hearing, or who have a language barrier. “I do think you lose a little bit of that personal bonding,” Talbot said. And prior to the lifting of universal masking at Vanderbilt, he said, some staff were telling him that one out of 10 times they’d ask a patient or family to mask, the exchange would “get antagonistic.”

    Read: The pandemic’s legacy is already clear

    When lifting mandates, many of the hospital epidemiologists I spoke with were careful to message to colleagues that the situation was fluid: “We’re suspending universal masking temporarily,” as Landon put it to her colleagues. Still, she admits that she felt uncomfortable returning to a low-mask norm at all. (When she informally polled nearly two dozen other hospital epidemiologists around the country in the spring, most of them told her that they felt the same.) Health-care settings aren’t meant to look like the rest of the world; they are places where precautions are expected to go above and beyond. COVID’s arrival had cemented masks’ ability to stop respiratory spread in close quarters; removing them felt to Landon like pushing those data aside, and putting the onus on patients—particularly those already less likely to advocate for themselves—to account for their own protection.

    She can still imagine a United States in which a pandemic-era response solidified, as it has in several other countries, into a peacetime norm: where wearing masks would have remained as routine as donning gloves while drawing blood, a tangible symbol of pandemic lessons learned. Instead, many American hospitals will be entering their fourth COVID winter looking a lot like they did in early 2020—when the virus surprised us, when our defenses were down.

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    Katherine J. Wu

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  • Long-Haulers Are Trying to Define Themselves

    Long-Haulers Are Trying to Define Themselves

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    Imagine you need to send a letter. The mailbox is only two blocks away, but the task feels insurmountable. Air hunger seizes you whenever you walk, you’re plagued by dizziness and headaches, and anyway, you keep blanking on your zip code for the return address. So you sit in the kitchen, disheartened by the letter you can’t send, the deadlines you’ve missed, the commitments you’ve canceled. Months have passed since you got COVID. Weren’t you supposed to feel better by now?

    Long COVID is a diverse and confusing condition, a new disease with an unclear prognosis, often-fluctuating symptoms, and a definition people still can’t agree on. And in many cases, it is disabling. In a recent survey, 1.6 percent of American adults said post-COVID symptoms limit their daily activities “a lot.” That degree of upheaval aligns with the Americans With Disabilities Act’s definition of disability: “a physical or mental impairment that substantially limits one or more major life activities.”

    But for many people experiencing long COVID who were able-bodied before, describing themselves as “disabled” is proving to be a complicated decision. This country is not kind to disabled people: American culture and institutions tend to operate on the belief that a person’s worth derives from their productivity and physical or cognitive abilities. That ableism was particularly stark in the early months of the pandemic, when some states explicitly de-prioritized certain groups of disabled people for ventilators. Despite the passage of the ADA in 1990, disabled people still confront barriers accessing things such as jobs and health care, and even a meal with friends at a restaurant. Most of our cultural narratives cast disability as either a tribulation to overcome or a tragedy.

    Consequently, incorporating disability into your identity can require a lot of reflection. Lizzie Jones, who finished her doctoral research in disability studies last year and now works for an educational consultancy, suffered a 30-foot fall that shattered half of her body a week before her college graduation. She told me that her accident prompted “radical identity shifts” as she transitioned from trying to get the life she’d imagined back on track to envisioning a new one.

    These are the sorts of mindset changes that Ibrahim Rashid struggled with after contracting COVID in November 2020, when he was a graduate student. He dealt with debilitating symptoms for months, but even after applying for disability accommodations to finish his degree, he “was so scared of that word,” he told me. Rashid was afraid of people treating him differently and of losing his internship offer. Most terrifying, calling himself disabled felt like an admission that his long COVID wasn’t going to suddenly resolve.

    Jennifer Senior: What not to ask me about my long COVID

    Aaron Teasdale, an outdoors and travel writer and a mountaineer, has also been wrestling with identity questions since he got COVID in January 2022. For months, he spent most of his time in a remote-controlled bed, gazing out the window at the Montana forests he once skied. Although his fatigue is now slowly improving, he had to take Ritalin to speak with me. He was still figuring out what being disabled meant to him, whether it simply described his current condition or reflected some new, deeper part of himself—a reckoning made more difficult by the unknowability of his prognosis. “Maybe I just need more time before I say I’m a disabled person,“ he said. “When you have your greatest passions completely taken away from you, it does leave you questioning, Well, who am I?”

    Long COVID can wax and wane, leaving people scrambling to adapt. It doesn’t mesh with the stereotype of disability as static, visible, and binary—the wheelchair user cast in opposition to the pedestrian. Nor does the fact that long COVID is often imperceptible in casual interactions, which forces long-haulers to contend with disclosure and the possibility of passing as able-bodied. One such long-hauler is Julia Moore Vogel, a program director at Scripps Research, who initially hesitated at the idea of getting a disabled-parking permit. “My first thought was, I’m not disabled, because I can walk,” she told me. But if she did walk, she’d be drained for days. Taking her daughter to the zoo or the beach was out of the question.

    Once she got over her apprehension, identifying as disabled ended up feeling empowering. Getting that permit was “one of the best things I’ve done for myself,” Vogel told me. She could drive her kid to the playground, park nearby, and then sit and watch her play. After plenty of therapy and conversations with other disabled people, Rashid, too, came to embrace disability as part of his identity, so much so that he now speaks and writes about chronic illness.

    Read: The future of long COVID

    Usually, the community around a disease—including advocacy among those it disables—arises after scientists name it. Long COVID upended that order, because the term first spread through hashtags and support groups in 2020. Instead of doctors informing patients of whether their symptoms fit a certain illness, patients were telling doctors what symptoms their illness entailed. And there were a lot of symptoms: everything from life-altering neurocognitive problems and dizziness to a mild, persistent cough.

    As long-COVID networks blossomed online, members began seeking support from wider disability-rights communities, and contributing fresh energy and resources to those groups. People who’d fought similar battles for decades sometimes bristled at the greater political capital afforded to long-haulers, whose advocacy didn’t universally extend to other disabled people; for the most part, though, long-haulers were welcomed.

    Tapping into conversations among disabled people “has shown me that I’m simply not alone,” Eris Eady, a writer and an artist who works for Planned Parenthood, told me. Eady, who is queer and Black, found that long COVID interplayed with struggles they already faced on account of their identity. So they sought advice from disabled Black women about interdependence, mutual aid, and accessibility, as well as about being dismissed by doctors, an experience more prevalent among women and people of color.

    Disabled communities have years of experience supporting people through identity changes. The writer and disability-justice organizer Leah Lakshmi Piepzna-Samarasinha told me that when she was newly disabled, she was dogged with heavy questions: Am I going to be able to make a living? Am I datable? Her isolation and fear dissipated only when she met other young disabled people, who taught her how to be creative in “hacking the world.”

    For long-haulers navigating these transitions for the first time, the process can be rocky. Rachel Robles, a contributor to The Long COVID Survival Guide, told me she spent her early months with long COVID “waking up every day and thinking, Okay, is this the day it’s left my body?” Conceiving of herself as disabled didn’t take away her long COVID. She didn’t stop seeing doctors and trying treatments. But thinking about accessibility did inspire her to return to gymnastics, which she’d quit decades earlier because of a heart condition. If she couldn’t lift her hands over her head sometimes, and if a dive roll would never be in her future, then so be it: Gymnastics could be about enjoying what her body could do, not yearning for what it couldn’t. Before she identified as disabled, returning to gymnastics “was something I would have never, ever imagined,” Robles said. And she never would have done it had she remained focused only on when she might recover.

    Read: Long COVID is being erased—again

    Hoping for improvement is a natural response to illness, especially one with a trajectory as uncertain as long COVID’s. But focusing exclusively on relinquished past identities or unrealized future ones can dampen our curiosity about the present. A better way to think about it is “What are the things you can do with the body that you have, and what are the things you might not know you can do yet?” Piepzna-Samarasinha said. “Who am I right now?”

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    Lindsay Ryan

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  • Long COVID Is Being Erased—Again

    Long COVID Is Being Erased—Again

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    Updated at 6:29 p.m. ET on April 21, 2023

    Charlie McCone has been struggling with the symptoms of long COVID since he was first infected, in March 2020. Most of the time, he is stuck on his couch or in his bed, unable to stand for more than 10 minutes without fatigue, shortness of breath, and other symptoms flaring up. But when I spoke with him on the phone, he seemed cogent and lively. “I can appear completely fine for two hours a day,” he said. No one sees him in the other 22.  He can leave the house to go to medical appointments, but normally struggles to walk around the block. He can work at his computer for an hour a day. “It’s hell, but I have no choice,” he said. Like many long-haulers, McCone is duct-taping himself together to live a life—and few see the tape.

    McCone knows 12 people in his pre-pandemic circles who now also have long COVID, most of whom confided in him only because “I’ve posted about this for three years, multiple times a week, on Instagram, and they’ve seen me as a resource,” he said. Some are unwilling to go public, because they fear the stigma and disbelief that have dogged long COVID. “People see very little benefit in talking about this condition publicly,” he told me. “They’ll try to hide it for as long as possible.”

    I’ve heard similar sentiments from many of the dozens of long-haulers I’ve talked with, and the hundreds more I’ve heard from, since first reporting on long COVID in June 2020. Almost every aspect of long COVID serves to mask its reality from public view. Its bewilderingly diverse symptoms are hard to see and measure. At its worst, it can leave people bed- or housebound, disconnected from the world. And although milder cases allow patients to appear normal on some days, they extract their price later, in private. For these reasons, many people don’t realize just how sick millions of Americans are—and the invisibility created by long COVID’s symptoms is being quickly compounded by our attitude toward them.

    Most Americans simply aren’t thinking about COVID with the same acuity they once did; the White House long ago zeroed in on hospitalizations and deaths as the measures to worry most about. And what was once outright denial of long COVID’s existence has morphed into something subtler: a creeping conviction, seeded by academics and journalists and now common on social media, that long COVID is less common and severe than it has been portrayed—a tragedy for a small group of very sick people, but not a cause for societal concern. This line of thinking points to the absence of disability claims, the inconsistency of biochemical signatures, and the relatively small proportion of severe cases as evidence that long COVID has been overblown. “There’s a shift from ‘Is it real?’ to ‘It is real, but …,’” Lekshmi Santhosh, the medical director of a long-COVID clinic at UC San Francisco, told me.

    Yet long COVID is a substantial and ongoing crisis—one that affects millions of people. However inconvenient that fact might be to the current “mission accomplished” rhetoric, the accumulated evidence, alongside the experience of long haulers, makes it clear that the coronavirus is still exacting a heavy societal toll.

    As it stands, 11 percent of adults who’ve had COVID are currently experiencing symptoms that have lasted for at least three months, according to data collected by the Census Bureau and the CDC through the national Household Pulse Survey. That equates to more than 15 million long-haulers, or 6 percent of the U.S. adult population. And yet, “I run into people daily who say, ‘I don’t know anyone with long COVID,’” says Priya Duggal, an epidemiologist and a co-lead of the Johns Hopkins COVID Long Study. The implication is that the large survey numbers cannot be correct; given how many people have had COVID, we’d surely know if one in 10 of our contacts was persistently unwell.

    But many factors make that unlikely. Information about COVID’s acute symptoms was plastered across our public spaces, but there was never an equivalent emphasis that even mild infections can lead to lasting and mercurial symptoms; as such, some people who have long COVID don’t even know what they have. This may be especially true for the low-income, rural, and minority groups that have borne the greatest risks of infection. Lisa McCorkell, a long-hauler who is part of the Patient-Led Research Collaborative, recently attended a virtual meeting of Bay Area community leaders, and “when I described what it is, some people in the chat said, ‘I just realized I might have it.’”

    Admitting that you could have a life-altering and long-lasting condition, even to yourself, involves a seismic shift in identity, which some people are understandably loath to make. “Everyone I know got Omicron and got over it, so I really didn’t want to concede that I didn’t survive this successfully,” Jennifer Senior, a friend and fellow staff writer at The Atlantic, who has written about her experience with long COVID, told me. Duggal mentioned an acquaintance who, after a COVID reinfection, can no longer walk the quarter mile to pick her kids up from school, or cook them dinner. But she has turned down Duggal’s offer of an appointment; instead, she is moving across the country for a fresh start. “That is common: I won’t call it ‘long COVID’; I’ll just change everything in my life,” Duggal told me. People who accept the condition privately may still be silent about it publicly. “Disability is often a secret we keep,” Laura Mauldin, a sociologist who studies disability, told me. One in four Americans has a disability; one in 10 has diabetes; two in five have at least two chronic diseases. In a society where health issues are treated with intense privacy, these prevalence statistics, like the one-in-10 figure for long COVID, might also intuitively feel like overestimates.

    Some long-haulers are scared to disclose their condition. They might feel ashamed for still being sick, or wary about hearing from yet another loved one or medical professional that there’s nothing wrong with them. Many long-haulers worry that they’ll be perceived as weak or needy, that their friends will stop seeing them, or that employers will treat them unfairly. Such fears are well founded: A British survey of almost 1,000 long-haulers found that 63 percent experienced overt discrimination because of their illness at least “sometimes,” and 34 percent sometimes regretted telling people that they have long COVID. “So many people in my life have reached out and said, ‘I’m experiencing this,’ but they’re not telling the rest of our friends,” McCorkell said.

    Imagine that you interact with 50 people on a regular basis, all of whom got COVID. If 10 percent are long-haulers, that’s five people who are persistently sick. Some might not know what long COVID is or might be unwilling to confront it. The others might have every reason to hide their story. “Numbers like 10 percent are not going to naturally present themselves in front of you,” McCone told me. Instead, “you’ll hear from 45 people that they are completely fine.”

    Illustration by Paul Spella / The Atlantic; Getty

    The same factors that stop people from being public about their condition—ignorance, denial, or concerns about stigma—also make them less likely to file for disability benefits. And that process is, to put it mildly, not easy. Applicants need thorough medical documentation; many long-haulers struggle to find doctors who believe their symptoms are real. Even with the right documents, applicants must hack their way through bureaucratic overgrowth, likely while fighting fatigue or brain fog. For these reasons, attempting to measure long COVID through disability claims is a profoundly flawed exercise. Even if people manage to apply, they face an average wait time of seven months and a two-in-three denial rate. McCone took six weeks to put an application together, and, despite having a lawyer and extensive medical documentation, was denied after one day. McCorkell knows many first-wavers—people who’ve had long COVID since March 2020—“who are just getting their approvals now.”

    An alternative source of data comes from the Census Bureau’s Current Population Survey, which simply asks working-age Americans if they have any of six forms of disability. Using that data, Richard Deitz, an economics-research adviser at the Federal Reserve Bank of New York, calculated that about 1.7 million more people now say they do than in mid-2020, reversing a years-long decline. These numbers are lower than expected if one in 10 people who gets COVID really does become a long-hauler, but the survey doesn’t directly capture many of the condition’s most common symptoms, such as fatigue, neurological problems beyond brain fog, and post-exertional malaise, where a patient’s symptoms get dramatically worse after physical or mental exertion. About 900,000 of the newly disabled people are also still working. David Putrino, who leads a long-COVID rehabilitation clinic at Mount Sinai, told me that many of his patients are refused the accommodations required under the Americans With Disabilities Act. Their employers won’t allow them to work remotely or reduce their hours, because, he said, “you look at them and don’t see an obvious disability.”

    Long COVID can also seem bafflingly invisible when people look at it with the wrong tools. For example, a 2022 study by National Institutes of Health researchers compared 104 long-haulers with 85 short-term COVID patients and 120 healthy people and found no differences in measures of heart or lung capacities, cognitive tests, or levels of common biomarkers—bloodstream chemicals that might indicate health problems. This study has been repeatedly used as evidence that long COVID might be fictitious or psychosomatic, but in an accompanying editorial, Aluko Hope, the medical director of Oregon Health and Science University’s long-COVID program, noted that the study exactly mirrors what long-haulers commonly experience: They undergo extensive testing that turns up little and are told, “Everything is normal and nothing is wrong.”

    The better explanation, Putrino told me, is that “cookie-cutter testing” doesn’t work—a problem that long COVID shares with other neglected complex illnesses, such as myalgic encephalomyelitis/chronic-fatigue syndrome and dysautonomia. For example, the NIH study didn’t consider post-exertional malaise, a cardinal symptom of both ME/CFS and long COVID; measuring it requires performing cardiopulmonary tests on two successive days. Most long-haulers also show spiking heart rates when asked to simply stand against a wall for 10 minutes—a sign of problems with their autonomic nervous system. “These things are there if you know where to look,” Putrino told me. “You need to listen to your patients, hear where the virus is affecting them, and test accordingly.”

    Contrary to popular belief, researchers have learned a huge amount about the biochemical basis of long COVID, and have identified several potential biomarkers for the disease. But because long COVID is likely a cluster of overlapping conditions, there might never be a singular blood test that “will tell you if you have long COVID 100 percent of the time,” Putrino said. The best way to grasp the scale of the condition, then, is still to ask people about their symptoms.

    Large attempts to do this have been relatively consistent in their findings: The U.S. Household Pulse Survey estimates that one in 10 people who’ve had COVID currently have long COVID; a large Dutch study put that figure at one in eight. The former study also estimated that 6 percent of American adults are long-haulers; a similar British survey by the Office for National Statistics estimated that 3 percent of the general population is. These cases vary widely in severity, and about one in five long-haulers is barely affected by their symptoms—but the remaining majority very much is. Another one in four long-haulers (or 4 million Americans) has symptoms that severely limit their daily activities. The others might, at best, wake every day feeling as if they haven’t had any rest, or feel trapped in an endless hangover. They might work or socialize when their tidal symptoms ebb, but only by making big compromises: “If I work a full day, I can’t also then make dinner or parent without significant suffering,” JD Davids, who has both long COVID and ME/CFS, told me.

    Some people do recover. A widely cited Israeli study of 1.9 million people used electronic medical records to show that most lingering COVID symptoms “are resolved within a year from diagnosis,” but such data fail to capture the many long-haulers who give up on the medical system precisely because they aren’t getting better or are done with being disbelieved. Other studies that track groups of long-haulers over time have found less rosy results. A French one found that 85 percent of people who had symptoms two months after their infection were still symptomatic after a year. A Scottish team found that 42 percent of its patients had only partially recovered at 18 months, and 6 percent had not recovered at all. The United Kingdom’s national survey shows that 69 percent of people with long COVID have been dealing with symptoms for at least a year, and 41 percent for at least two.

    The most recent data from the U.S. and the U.K. show that the total number of long-haulers has decreased over the past six months, which certainly suggests that people recover in appreciable numbers. But there’s a catch: In the U.K., the number of people who have been sick for more than a year, or who are severely limited by their illness, has gone up. A persistent pool of people is still being pummeled by symptoms—and new long-haulers are still joining the pool. This influx should be slower than ever, because Omicron variants seem to carry a lower risk of triggering long COVID, while vaccines and the drug Paxlovid can lower that risk even further. But though the odds against getting long COVID are now better, more people are taking a gamble, because preventive precautions have been all but abandoned.

    Even if prevalence estimates were a tenth as big, that would still mean more than 1 million Americans are dealing with a chronic illness that they didn’t have three years ago. “When long COVID first came on the scene, everyone told us that once we have the prevalence numbers, we can do something about it,” McCorkell told me. “We got those numbers. Now people say, ‘Well, we don’t believe them. Try again.’”

    To a degree, I sympathize with some of the skepticism regarding long COVID, because the condition challenges our typical sense of what counts as solid evidence. Blood tests, electronic medical records, and disability claims all feel like rigorous lines of objective data. Their limitations become obvious only when you consider what the average long-hauler goes through—and those details are often cast aside because they are “anecdotal” and, by implication, unreliable. This attitude is backwards: The patients’ stories are the ground truth against which all other data must be understood. Gaps between the data and the stories don’t immediately invalidate the latter; they just as likely show the holes in the former.

    Laura Mauldin, the disability sociologist, argues that the U.S. is primed to discount those experiences because the country’s values—exceptionalism, strength, self-reliance—have created what she calls the myth of the able-bodied public. “We cannot accept that our bodies are fallible, or that disability is utterly ordinary and expected,” she told me. “We go to great pains to pretend as though that is not the case.” If we believe that a disabling illness like long COVID is rare or mild, “we protect ourselves from having to look at it.” And looking away is that much easier because chronic illnesses like long COVID are more likely to affect women—“who are more likely to have their symptoms attributed to psychological problems,” Mauldin said—and because the American emphasis on work ethic devalues people who can’t work as much or as hard as their peers.

    Other aspects of long COVID make it hard to grasp. Like other similar, neglected chronic illnesses, it defies a simplistic model of infectious disease in which a pathogen causes a predictable set of easily defined symptoms that alleviate when the bug is destroyed. It challenges our belief in our institutions, because truly contending with what long-haulers go through means acknowledging how poorly the health-care system treats chronically ill patients, how inaccessible social support is to them, and how many callous indignities they suffer at the hands of even those closest to them. Long COVID is a mirror on our society, and the image it reflects is deeply unflattering.

    Most of all, long COVID is a huge impediment to the normalization of COVID. It’s an insistent indicator that the pandemic is not actually over; that policies allowing the coronavirus to spread freely still carry a cost; that improvements such as better indoor ventilation are still wanting; that the public emergency may have been lifted but an emergency still exists; and that millions cannot return to pre-pandemic life. “Everyone wants to say goodbye to COVID,” Duggal told me, “and if long COVID keeps existing and people keep talking about it, COVID doesn’t go away.” The people who still live with COVID are being ignored so that everyone else can live with ignoring it.

    This article originally misstated the name of the bank where Richard Deitz works.

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    Ed Yong

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  • Long COVID Hitting Some States, Minorities, Women Harder

    Long COVID Hitting Some States, Minorities, Women Harder

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    April 7, 2023 – More than 3 years into the COVID-19 pandemic, lasting symptoms are becoming quite common, with residents of certain states, women, Hispanic people, and transgender people more at risk, a new report shows. 


    More than one in four adults sickened by the virus go on to have long COVID, according to a new 

    report

    from the U.S. Census Bureau. Overall, nearly 15% of 

    all American adults

    – more than 38 million people nationwide – have had long COVID at some point since the start of the pandemic, according to the report. 


    The report, based on survey data collected between March 1 and 13, defines long COVID as symptoms lasting at least 3 months that people didn’t have before getting infected with the virus. 


    It is the second recent look at who is most likely to face long COVID.

    A similar study

    , published last month, found that women, smokers, and those who had severe COVID-19 infections are most likely to have the disorder


    The Census Bureau report found that while 27% of adults nationwide have had long COVID after getting infected with the virus, the condition has impacted some states more than others. The proportion of residents hit with long COVID ranged from a low of 18.8% in New Jersey to a high of 40.7% in West Virginia. 


    Other states with long COVID rates well below the national average include Alaska, Maryland, New York, and Wisconsin. At the other end of the spectrum, the states with rates well above the national average include Kentucky, Mississippi, New Mexico, Nevada, South Carolina, South Dakota, and Wyoming.


    Long COVID rates also varied by age, gender, and race. People in their 50s were most at risk, with about 31% of those infected by the virus going on to have long COVID, followed by those in their 40s, at more than 29%. 


    Far more women (almost 33%) than men (21%) with COVID infections got long COVID. And when researchers looked at long COVID rates based on gender identity, they found that transgender adults were more than twice as likely to have long COVID than cisgender males. Bisexual adults also had much higher long COVID rates than straight, gay, or lesbian people. 


    Long COVID was also much more common among Hispanic adults, affecting almost 29% of those infected with the virus, than among White or Black people, who had long COVID rates similar to the national average of 27%. Asian adults had lower long COVID rates than the national average, at less than 20%.


    People with disabilities were also at higher risk, with long COVID rates of almost 47%, compared with 24% among adults without disabilities.

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  • Doctor’s Checklist for Treating Long COVID Patients

    Doctor’s Checklist for Treating Long COVID Patients

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    April 4, 2023 – Lisa McCorkell had a mild bout of COVID-19 in March 2020. Young and healthy, she assumed that she would bounce back quickly. But when her fatigue, shortness of breath, and brain fog persisted, she realized that she most likely had long COVID. 

    “Back then, we as patients basically coined the term,” she said. While her first primary care provider was sympathetic, they were unsure how to treat her. After her insurance changed, she ended up with a second primary care provider who didn’t take her symptoms seriously. “They dismissed my complaints and told me they were all in my head. I didn’t seek care for a while after that.”

    McCorkell’s symptoms improved after her first COVID vaccine in the spring of 2021. She also finally found a new primary care doctor she could trust. But as one of the founders of the Patient-Led Research Collaborative, a group of researchers who study long COVID, she says many doctors still don’t know the hallmark symptoms of the condition or how to treat it. 

    “There’s still a lack of education on what long COVID is, and the symptoms associated with it,” she said. “Many of the symptoms that occur in long COVID are symptoms of other chronic conditions, such as chronic fatigue syndrome, that are often dismissed. And even if providers believe patients and send them for a workup, many of the routine blood and imaging tests come back normal.”

    The term “long COVID” emerged in May 2020. And though the condition was recognized within a few months of the start of the pandemic, doctors weren’t sure how to screen or treat it. 

    While knowledge has developed since then, primary care doctors are still in a tough spot. They’re often the first providers that patients turn to when they have symptoms of long COVID. But with no standard diagnostic tests, treatment guidelines, standard care recommendations, and a large range of symptoms the condition can produce, doctors may not know what to look for, nor how to help patients.

    “There’s no clear algorithm to pick up long COVID – there are no definite blood tests or biomarkers, or specific things to look for on a physical exam,” said Lawrence Purpura, MD, an infectious disease specialist and director of the long COVID clinic at Columbia University Medical Center in New York City. “It’s a complicated disease that can impact every organ system of the body.”

    Even so, emerging research has identified a checklist of sorts that doctors should consider when a patient seeks care for what appears to be long COVID. Among them:

    • The key systems and organs impacted by the disease
    • The most common symptoms
    • Useful therapeutic options for symptom management that have been found to help people with long COVID
    • The best heathy lifestyle choices that doctors can recommend to help their patients 

    Here’s a closer look at each of these aspects, based on research and interviews with experts, patients, and doctors. 

    Key Systems, Organs Impacted                                                                                                 

    About 10% of people who are infected with COVID-19 go on to have long COVID, according to a recent study that McCorkell helped co-author. But more than 3 years into the pandemic, much about the condition is still a mystery. 

    COVID is a unique virus because it can spread far and wide in a patient’s body. A December 2022 study, published in the journal Nature, autopsied 44 people who died of COVID and found that the virus could spread throughout the body and persist, in one case as long as 230 days after symptoms started. 

    “We know that there are dozens of symptoms across multiple organ systems,” said McCorkell. “That makes it harder for a primary care physician to connect the dots and associate it with COVID.”

    A paper published last December in Nature Medicine proposed one way to help guide diagnosis. It divided symptoms into four groups: 

    • Cardiac and renal issues such as heart palpitations, chest pain, and kidney damage
    • Sleep and anxiety problems like insomnia, waking up in the middle of the night, and anxiety
    • In the musculoskeletal and nervous systems: musculoskeletal pain, osteoarthritis, and problems with mental skills
    • In the digestive and respiratory systems: trouble breathing, asthma, stomach pain, nausea, and vomiting

    There were also specific patterns in these groups. People in the first group were more likely to be older, male, have other conditions and to have been infected during the first wave of the COVID pandemic. People in the second group were over 60% female, and were more likely to have had previous allergies or asthma. The third group was also about 60% female, and many of them already had autoimmune conditions such as rheumatoid arthritis. Members of the fourth group – also 60% female – were the least likely of all the groups to have another condition.

    This research is helpful, because it gives doctors a better sense of what conditions might make a patient more likely to get long COVID, as well as specific symptoms to look out for, said Steven Flanagan, MD, a physical medicine and rehabilitation specialist at NYU Langone Medical Center who also specializes in treating patients with long COVID. 

    But the “challenge there, though, for health care providers is that not everyone will fall neatly into one of these categories,” he stressed.

    Checklist of Symptoms 

    Although long COVID can be confusing, doctors say there are several symptoms that appear consistently that primary care providers should look out for, that could flag long COVID. They include:

    Post-exertional malaise (PEM). This is different from simply feeling tired. “This term is often conflated with fatigue, but it’s very different,” said David Putrino, PhD, director of rehabilitation innovation at the Mount Sinai Health System in New York City, who says that he sees it in about 90% of patients who come to his long COVID clinic. 

    PEM is the worsening of symptoms after physical or mental exertion. This usually occurs a day or two after the activity, but it can last for days, and sometimes weeks. 

    “It’s very different from fatigue, which is just a generalized tiredness, and exercise intolerance, where someone complains of not being able to do their usual workout on the treadmill,” he noted. “People with PEM are able to push through and do what they need to do, and then are hit with symptoms anywhere from 12 to 72 hours later.”

    Dysautonomia. This is an umbrella term used to describe a dysfunction of the autonomic nervous system, which regulates bodily functions that you can’t control, like your blood pressure, heart rate, and breathing. This can cause symptoms such as heart palpitations, along with orthostatic intolerance, which means you can’t stand up for long without feeling faint or dizzy. 

    “In my practice, about 80% of patients meet criteria for dysautonomia,” said Putrino. Other research has found that it’s present in about two-thirds of long COVID patients.

    One relatively easy way primary care providers can diagnose dysautonomia is to do the tilt table test. This helps check for postural orthostatic tachycardia syndrome (POTS), one of the most common forms of dysautonomia. During this exam, the patient lies flat on a table. As the head of the table is raised to an almost upright position, their heart rate and blood pressure are measured. Signs of POTS include an abnormal heart rate when you’re upright, as well as a worsening of symptoms.

    Exercise intolerance. A 2022 review published in the journal JAMA Network Open analyzed 38 studies on long COVID and exercise and found that patients with the condition had a much harder time doing physical activity. Exercise capacity was reduced to levels that would be expected about a decade later in life, according to study authors. 

    “This is especially important because it can’t be explained just by deconditioning,” said Purpura. “Sometimes these patients are encouraged to ramp up exercise as a way to help with symptoms, but in these cases, encouraging them to push through can cause post-exertional malaise, which sets patients back and delays recovery.”

    While long COVID can cause dozens of symptoms, a paper McCorkell co-authored zeroed in on some of the most common ones:

    • Chest pain
    • Heart palpitations
    • Coughing
    • Shortness of breath
    • Belly pain
    • Nausea
    • Problems with mental skills
    • Fatigue
    • Disordered sleep
    • Memory loss
    • Ringing in the ears (tinnitus)
    • Erectile dysfunction
    • Irregular menstruation
    • Worsened premenstrual syndrome

    While most primary care providers are familiar with some of these long COVID symptoms, they may not be aware of others. 

    “COVID itself seems to cause hormonal changes that can lead to erection and menstrual cycle problems,” explained Putrino. “But these may not be picked up in a visit if the patient is complaining of other signs of long COVID.” 

    It’s not just what symptoms are, but when they began to occur, he added. 

    “Usually, these symptoms either start with the initial COVID infection, or begin sometime within 3 months after the acute COVID infection. That’s why it’s important for people with COVID to take notice of anything unusual that crops up within a month or two after getting sick.”

    Can You Prevent Long COVID?

    You can’t, but one of the best ways to reduce your risk is to get vaccinated. Getting at least one dose of a COVID vaccine before you test positive for COVID lowers your risk of long COVID by about 35% according to a 2022 study published in Antimicrobial Stewardship & Healthcare Epidemiology. Unvaccinated people who recovered from COVID, and then got a vaccine, lowered their own long COVID risk by 27%. 

    In addition, a February study published in JAMA Internal Medicine found that women who were infected with COVID were less likely to go on to get long COVID and/or have less debilitating symptoms if they had a healthy lifestyle, which included the following: 

    • Healthy weight (a BMI between 18.5 and 24.7)
    • Never smoker
    • Moderate alcohol consumption
    • A high-quality diet
    • Seven to 9 hours of sleep a night
    • At least 150 minutes per week of physical activity

    But McCorkell noted that she herself had a healthy pre-infection lifestyle but got long COVID anyway, suggesting these approaches don’t work for everyone.

    “I think one reason my symptoms weren’t addressed by primary care physicians for so long is because they looked at me and saw that I was young and healthy, so they dismissed my reports as being all in my head,” she explained. “But we know now anyone can get long COVID, regardless of age, health status, or disease severity. That’s why it’s so important that primary care physicians be able to recognize symptoms.”

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  • Bias, Lack of Access Make Long COVID Worse for Patients of Color

    Bias, Lack of Access Make Long COVID Worse for Patients of Color

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    March 28, 2023 – Over and over, Mesha Liely was told that it was all in her head. That she was just a woman prone to exaggeration. That she had anxiety. That she simply needed to get more rest and take better care of herself. 

    The first time an ambulance rushed her to the emergency room in October 2021, she was certain something was seriously wrong. Her heart raced, her chest ached, she felt flushed, and she had numbness and tingling in her arms and legs. And she had recently had COVID-19. But after a 4-day hospital stay and a battery of tests, she was sent home with no diagnosis and told to see a cardiologist. 

    More than a dozen trips to the emergency room followed over the next several months. Liely saw a cardiologist and several other specialists: a gastroenterologist; an ear, nose, and throat doctor; a vascular doctor; and a neurologist. She got every test imaginable. But she still didn’t get a diagnosis. 

    “I believe more times than not, I was dismissed,” said Liely, 32, who is Black. “I am female. I am young. I am a minority. The odds are up against me.”

    By the time she finally got a diagnosis in May 2022, she felt like a bobble-head with weakness in her arms and legs, rashes and white patches of skin along the right side of her body, distorted vision, swelling and discomfort in her chest, and such a hard time with balance and coordination that she often struggled to walk or even stand up.

    “I was in a wheelchair when the doctor at Hopkins told me I had long COVID,” Liely said. “I just broke down and cried. The validation was the biggest thing for me.”

    Stark racial and ethnic disparities in who gets sick and who receives treatment have been clear since the early days of the pandemic. Black and Hispanic patients were more likely to get COVID than white people, and, when they did get sick, they were more likely to be hospitalized and more apt to die.

    Now, an emerging body of evidence also suggests that Black and Hispanic patients are also more likely to have long COVID – and more likely to get a broader range of symptoms and serious complications when they do. 

    One study recently published this year in the Journal of General Internal Medicine followed more than 62,000 adults in New York City who had COVID between March 2020 and October 2021. Researchers tracked their health for up to 6 months, comparing them to almost 250,000 people who never had COVID. 

    Among the roughly 13,000 people hospitalized with severe COVID, 1 in 4 were Black and 1 in 4 were Hispanic, while only 1 in 7 were white, this study found. After these patients left the hospital, Black adults were much more likely than white people to have headaches, chest pain, and joint pain. And Hispanic patients were more apt to have headaches, shortness of breath, joint pain, and chest pain.

    There were also racial and ethnic disparities among patients with milder COVID cases. Among people who weren’t hospitalized, Black adults were more likely to have blood clots in their lungs, chest pain, joint pain, anemia, or be malnourished. Hispanic adults were more likely than white adults to have dementia, headaches, anemia, chest pain, and diabetes. 

    Yet research also suggests that white people are more likely to get diagnosed and treated for long COVID. A separate study published this year in the journal BMC Medicine offers a profile of a typical long COVID patient receiving care at 34 medical centers across the country. And these patients are predominantly white, affluent, well-educated, female, and living in communities with great access to health care. 

    While more Black and Hispanic patients may get long COVID, “having symptoms of long COVID may not be the same as being able to get treatment.,” said Dhruv Khullar, MD, lead author of the New York City study and a doctor and assistant professor of health policy and economics at Weill Cornell Medical College in New York City.

    Many of the same issues that made many Black and Hispanic patients more vulnerable to infection during the pandemic may now be adding to their limited access to care for long COVID, Khullar said. 

    Nonwhite patients were more apt to have hourly jobs or be essential workers without any ability to telecommute to avoid COVID during the height of the pandemic, Khullar said. They’re also more likely to live in close quarters with family members or roommates and face long commutes on public transit, limiting their options for social distancing. 

    “If people that are going out of the home that are working in the subways or grocery stores or pharmacies or jobs deemed essential were disproportionately Black or Hispanic, they would have a much higher level of exposure to COVID than people who could work from home and have everything they needed delivered,” Khullar said. 

    Many of these hourly and low-wages workers are also uninsured or underinsured, lack paid sick time, struggle with issues like child care and transportation when they need checkups, and have less disposable income to cover copays and other out-of-pocket fees, Khullar said. “They can get access to acute urgent medical care, but it’s very hard for a lot of people to access routine care like you would need for long COVID,” Khullar says.

    These longstanding barriers to care are now contributing to more long COVID cases – and worse symptoms – among Black and Hispanic patients, said Alba Miranda Azola, MD, co-director of the Post-Acute COVID-19 Team at Johns Hopkins University School of Medicine in Baltimore. 

    “They basically push through their symptoms for too long without getting care either because they don’t see a doctor at all or because the doctor they do see doesn’t do anything to help” said Azola, who diagnosed Mesha Liely with long COVID. “By the time they get to me, their symptoms are much worse than they needed to be.”

    In many ways, Liely’s case is typical of the Black and Hispanic patients Azola sees with long COVID. “It’s not unusual for patients have 10 or even 15 visits to the emergency room without getting any help before they get to me,” Azola said. “Long COVID is poorly understood and underdiagnosed and they just feel gaslit.”

    What sets Liely apart is that her job as 911 operator comes with good health benefits and easy access to care. 

    “I started to notice a pattern where when I go to the ER and my co-workers are there or I am in my law enforcement uniform, and everyone is so concerned and takes me right back,” she recalled. “But when I would go dressed in my regular clothing, I would be waiting 8 to 10 hours and nobody would acknowledge me, or they would ask if I was just here to get pain medicines.”

    Liely can easily see how other long COVID patients who look like her might never get diagnosed at all. “It makes me mad but doesn’t surprise me,” she says. 

    After months of long COVID treatment, including medications for heart issues and muscle weakness as well as home health care, occupational therapy, and physical therapy, Liely went back to work in December. Now, she has good days and bad days. 

    “On the days I wake up and feel like I’m dying because I feel so bad, that’s when I really think it didn’t need to be like this if only I had been able to get somebody to listen to me sooner,” she said.

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  • Who Is Most Likely to Get Long COVID? Patient Data May Tell

    Who Is Most Likely to Get Long COVID? Patient Data May Tell

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    March 27, 2023 – Good news and bad news on the long COVID front: Certain groups of people – like women, smokers, and those who had severe COVID-19 infections – are at a higher risk of long COVID, a review of more than 800,000 patients has found. 

    That’s the bad news. Yet, researchers also found that patients who had at least two doses of the COVID vaccine had a significantly lower risk of getting long COVID down the line. 

    “Not only is it important to recognize which individuals may be at high risk of developing PCC [post−COVID-19 condition] and to offer follow-up care; it is imperative to plan population-level public health measures,” wrote lead author Vassilios Vassiliou, PhD, a professor of cardiac medicine at the University of East Anglia in Norwich, England, and his team. 

    The research, published in the journal JAMA Internal Medicine, combined 41 previously published articles that included information from 860,783 patients. The review uncovered a slew of demographic traits that were significantly linked to long COVID, including female sex, being over 40 years old, smoking, having a high body mass index (BMI), and hospitalization due to a COVID-19 infection. 

    Long COVID, as defined by the World Health Organization, is the continuation of COVID symptoms or the start of new symptoms at least 3 months after initial infection.

    Having other conditions – like anxiety, depression, asthma, diabetes, and being immunocompromised – were also connected to a higher likelihood of getting long COVID, researchers reported. 

    That cisgender women are at a higher risk of long COVID falls in line with previous analyses, suggesting that hormones might play a role “in perpetuating the hyperinflammatory status of the acute phase of COVID-19 even after recovery.” 

    The same goes for previous studies on vaccination status and long COVID risk – like much of the previous research on the subject, vaccinations were found to have a protective effect on long COVID. 

    But long COVID – all the ways it presents itself, how widespread it is, and what we can do about it – still remains somewhat of a mystery, even 3 years into the pandemic. 

    “While this and other data on vaccines suggest that there are factors that can reduce the risk of long COVID, nothing as of yet can completely eliminate the risk of long COVID. The only guarantee against long COVID is not to get COVID,” said Stanford University primary care professor Linda Geng, MD, PhD. 

     

    “Furthermore, we still do not have any effective therapy established for the millions who already have long COVID, and we urgently need randomized controlled trials to help provide those answers,” she said.

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  • ‘We’re Struggling’: Long COVID Mystery Has Doctors in the Dark

    ‘We’re Struggling’: Long COVID Mystery Has Doctors in the Dark

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    March 23, 2023 — This month, I took care of a patient who recently contracted COVID-19 and was complaining of chest pain. After ruling out the possibility of a heart attack, pulmonary embolism, or pneumonia, I concluded that this was a residual symptom of COVID. 

    Chest pain is a common lingering symptom of COVID. However, because of the scarcity of knowledge regarding these post-acute symptoms, I was unable to counsel my patient on how long this symptom would last, why he was experiencing it, or what its actual cause was. 

    Such is the state of knowledge on long COVID. That informational vacuum is why we’re struggling and doctors are in a tough spot when it comes to diagnosing and treating patients with the condition.

    Almost daily, new studies are published about long COVID (technically known as post-acute sequelae of COVID-19 [PASC]) and its societal impacts. These studies often calculate various statistics regarding the prevalence of this condition, its duration, and its scope. 

    However, many of these studies do not provide the complete picture — and they certainly do not when they are interpreted by t

    he lay press and turned into clickbait. 

    Long COVID is real, but there is a lot of context that is omitted in many of the discussions that surround it. Unpacking this condition and situating it in the larger context is an important means of gaining traction on this condition. 

    And that’s critical for doctors who are seeing patients with symptoms.

    Long COVID: What Is It?   

    The CDC considers long COVID to be an umbrella term for “health consequences” that are present at least 4 weeks after an acute infection. This condition can be considered “a lack of return to the usual state of health following COVID,” according to the CDC.

    Common symptoms include fatigue, shortness of breath, exercise intolerance, “brain fog,” chest pain, cough, and loss of taste/smell. Note that it’s not a requirement that that symptoms be severe enough that they interfere with activities of daily living, just that they are present.

    There is no diagnostic test or criteria that confirms this diagnosis. Therefore, the symptoms and definitions above are vague and make it difficult to gauge prevalence of the disease. Hence, the varying estimates that range from 5% to 30%, depending on the study. 

    Indeed, when one does routine blood work or imaging on these patients, it is unlikely that any abnormality is found. Some individuals, however, have met diagnostic criteria and have been diagnosed with postural orthostatic tachycardia syndrome (POTS). POTS is a disorder commonly found in long COVID patients that causes problems in how the autonomic nervous system regulates heart rate when moving from sitting to standing, during which blood pressure changes occur. 

    How to Distinguish Long COVID From Other Conditions

    There are important conditions that should be ruled out in the evaluation of someone with long COVID. First, any undiagnosed condition or change in an underlying condition that could explain the symptoms should be considered and ruled out. 

    Secondly, it is critical to recognize that those who were in the intensive care unit or even hospitalized with COVID should not really be grouped together with those who had uncomplicated COVID that did not require medical attention. 

    One reason for this is a condition known as post-ICU syndrome or PICS. PICS can occur in anyone who is admitted to the ICU for any reason and is likely the result of many factors common to ICU patients. They include immobility, severe disruption of sleep/wake cycles, exposure to sedatives and paralytics, and critical illness. 

    Those individuals are not expected to recover quickly and may have residual health problems that persist for years, depending on the nature of their illness. They even have heightened mortality. 

    The same is true, to a lesser extent, to those hospitalized whose “post-hospital” syndrome places them at higher risk for experiencing ongoing symptoms. 

    To be clear, this is not to say that long COVID does not occur in the more severely ill patients, just that it must be distinguished from these conditions. In the early stages of trying to define the condition, it is more difficult if these categories are all grouped together. The CDC definition and many studies do not draw this important distinction and may confuse long COVID with PICS and post-hospital syndrome.

    Control Groups in Studies Are Key

    Another important means to understand this condition is to conduct studies with control groups, directly comparing those who had COVID with those that did not. 

    Such a study design allows researchers to isolate the impact of COVID and separate it from other factors that could be playing a role in the symptoms. When researchers conduct studies with control arms, the prevalence of the condition is always lower than without. 

    In fact, one notable study demonstrated comparable prevalence of long COVID symptoms in those who had COVID versus those that believe they had COVID. 

    Identifying Risk Factors

    Several studies have suggested certain individuals may be overrepresented among long COVID patients. These risk factors for long COVID include women, those who are older, those with preexisting psychiatric illness (depression/anxiety), and those who are obese. 

    Additionally, other factors associated with long COVID include reactivation of Epstein-Barr virus (EBV), abnormal cortisol levels, and high viral loads of the coronavirus during acute infection. 

    None of these factors has been shown to play a causal role, but they are clues for an underlying cause. However, it is not clear that long COVID is monolithic — there may be subtypes or more than one condition underlying the symptoms. 

    Lastly, long COVID also appears to be only associated with infection by the non-Omicron variants of COVID.

    Role of Antivirals and Vaccines 

    The use of vaccines has been shown to lower, but not entirely eliminate, the risk of long COVID. This is a reason why low-risk individuals benefit from COVID vaccination. Some have also reported a therapeutic benefit of vaccination on long COVID patients. 

    Similarly, there are indications that antivirals may also diminish the risk for long COVID, presumably by influencing viral load kinetics. It will be important, as newer antivirals are developed, to think about the role of antivirals not just in the prevention of severe disease but also as a mechanism to lower the risk of developing persistent symptoms. 

    There may also be a role for other anti-inflammatory medications and other drugs such as metformin.

     Long COVID and Other Infectious Diseases 

    The recognition of long COVID has prompted many to wonder if it occurs with other infectious diseases. Those in my field of infectious disease have routinely been referred patients with persistent symptoms after treatment for Lyme disease or after recovery from the infectious mononucleosis. 

    Individuals with influenza may cough for weeks post-recovery, and even patients with Ebola may have persistent symptoms (though the severity of most Ebola causes makes it difficult to include). 

    Some experts suspect an individual human’s immune response may influence the development of post-acute symptoms. The fact that so many people were sickened with COVID at once allowed a rare phenomenon that always existed with many types of infections to become more visible.

    Where to Go From Here: A Research Agenda

    Before anything can be definitely said about long COVID, fundamental scientific questions must be answered. 

    Without an understanding of the biological basis of this condition, it becomes impossible to diagnose patients, development treatment regimens, or to prognosticate (though symptoms seem to dissipate over time). 

    It was recently said that unraveling the intricacies of this condition will lead to many new insights about how the immune system works — an exciting prospect in and of itself that will advance science and human health.

    Armed with that information, the next time clinicians see a patient such as the one I did, we will be in a much better position to explain to a patient why they are experiencing such symptoms, provide treatment recommendations, and offer prognosis. 

    Amesh A. Adalja, MD, is an infectious disease, critical care, and emergency medicine specialist in Pittsburgh, and senior scholar with the Johns Hopkins Center for Health Security.

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  • WebMD Poll: Another Year of Tough COVID Questions

    WebMD Poll: Another Year of Tough COVID Questions

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    March 15, 2023 — Last year, on the second anniversary of the COVID-19 pandemic, we asked our audience questions about their pandemic experiences. A year later – and 3 years into living with COVID – we followed up with some more. 

    In total, our poll received 696 responses. Nearly 66% of those who answered identified as female, and 76% reported that they are older than 45. The confidence level used for editorial polls is 95%. 

    The fall of 2022 started out with President Joe Biden claiming that “the pandemic is over” on CBS’s 60 Minutes. Since then, he has ordered an end to the COVID-19 emergency orders issued in 2020, causing people to wonder if this really might be the beginning of the end of the pandemic.

     In 2022, WebMD readers, for the most part (84%) did not see an end in sight. But a year later, attitudes seem to be shifting. Our current poll found that nearly a third – 30% – of our audience thinks the pandemic has  come to an end. However, 42% of men said the pandemic is over, compared to just 25% of women. 

    The data, however, says differently. While daily life may have returned to its normal pace and we’re no longer in the midst of a state of emergency, many experts agree that we shouldn’t let our guard down. New cases and the number of deaths per week have indeed leveled off since January 2022, but data shows that there are still thousands of new cases reported daily. And given the evolution of the virus’s many variants, doctors and public health officials continue to urge caution. 

    The availability of vaccines and boosters is a big part of why we all feel more comfortable doing the everyday tasks that we may have taken for granted during the pandemic’s first couple of years. How many people, though, are actually protected against the virus? According to our poll, 7 in 10 respondents have been fully vaccinated against COVID-19; nearly 6 in 10 of those fully vaccinated have received at least two boosters (57%).

    However, these numbers don’t totally reflect the reality of vaccine and booster uptake in the U.S. According to CDC data, Americans on the whole – quite similar to our findings – have completed their initial vaccination series at a rate of nearly 70%. But of those who have gotten fully vaccinated, only a little more than 23% have gotten at least one dose of the bivalent booster. 

    Sixty percent of respondents to our poll said that they have had COVID-19 at least once, which is notable when compared to an exhaustive nationwide survey that found that about half of Americans have had COVID. Within that study, however, researchers said there is a large chunk of positive at-home tests that have gone unreported. 

    Whether you had COVID-19 or not, the pandemic has undoubtedly changed the way we see and interact with the world around us. Last year, an overwhelming 88% of respondents agreed on this; this year, about half of our readers agreed with this statement – possibly indicating a growing acceptance of the changes happening around us.

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  • 3 Years On, Why Don’t We Know the Extent of Long COVID?

    3 Years On, Why Don’t We Know the Extent of Long COVID?

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    SOURCES:

    Amesh Adalja, MD, senior scholar, Johns Hopkins University Center for Health Security.

    Manali Mukherjee, PhD, immunologist, assistant professor, Division of Respirology, Department of Medicine, McMaster University.

    Sarah Wulf Hanson, PhD, research scientist, Institute for Health Metrics and Evaluation, University of Washington.

    Lisa McCorkell, co-founder, Patient-Led Research Collaborative.

    Julia Moore Vogel, PhD, program director, Participant Center, All of Us Research Program, Scripps Research Translational Institute.

    The BMJ: “Long COVID outcomes at one year after mild SARS-CoV-2 infection: nationwide cohort study.” 

    Nature Reviews Microbiology: “Long COVID: Major findings, mechanisms and recommendations.” 

    CDC National Center for Health Statistics: “Long COVID Household Pulse Survey.”

    Nature Medicine: “Unexplained post-acute infection syndromes.”

    Patient-Led Research Collaborative.

    World Health Organization: “Post COVID-19 condition (Long COVID).”

    CDC: “Post-COVID Conditions: CDC Science.”

    The European Respiratory Journal: “Circulating anti-nuclear autoantibodies in COVID-19 survivors predict long COVID symptoms.”

    Emerging Infectious Diseases: “Postacute Sequelae of SARS-CoV-2 in University Setting.”

    International Severe Acute Respiratory and emerging Infection Consortium (ISARIC): “Clinical Characterisation Protocol (CCP).”

     

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  • Future COVID Vaccines Must Be Better; Science Races to Respond

    Future COVID Vaccines Must Be Better; Science Races to Respond

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    SOURCES 

    David L. Hoey, president and CEO of Vaxxas, Cambridge, MA, and Brisbane, Australia.

    Pablo Penaloza-MacMaster, PhD, assistant professor of microbiology and immunology, Feinberg School of Medicine, Northwestern University, Chicago.

    Jasdave Chahal, PhD, co-founder and chief scientist, Tiba Biotech, Cambridge, MA, and Brisbane, Australia.

    Vaxart news release: “Vaxart Announced Positive Top-line Phase II clinical Study Data Demonstrating Safaety and Immunogenicity of Its Wuhan S-Only COVID-19 Pill Vaccine Candidate.”

    Mark Herr, spokesperson, Vaxart Inc. 

    The Commonwealth Fund: “Two Years of  U.S. COVID-19 Vaccines Have Prevented Millions of Hospitalizations and Deaths.”

    The Lancet Infectious Diseases: “Global impact of the first year of COVID-19 vaccination: a mathematical modelling study.” 

    CDC: COVID Data Tracker, “Needle Fears and Phobias—Find Ways to Manage.”

    U.S. Specialty Formulations news release: “Research Demonstrates Benefits of Oral COVID-19 Vaccine.”

    CanSino Biologics Inc. statement: “Inside Information.” 

    Coalition for Epidemic Preparedness Innovations:  Email statement; News releases: “The Race to Future-Proof Coronavirus Vaccines;.”  “Coming in from the cold: needle-free patch technology for mRNA vaccines aims to end need for frozen storage and improve access.” 

    Executive Office of  the President: “Statement of Administration Policy.”

    Science: “Mosaic RBD nanoparticles protect against challenge by diverse sarbecoviruses in animal models.”

    Caltech news release: “Nanoparticle Vaccine Protects Against a Spectrum of COVID-19-causing Variants and Related Viruses.”   

     

    U.S. Government Accountability Office. “Operation Warp Speed.”

    Bharat Biotech International Limited news release: “Bharat biotech launches iNCOVACC: World’s 1st intranasal COVID vaccine for Primary series and Heterologous booster.” 

    The Lancet preprints: “Immunogenicity and Tolerability of BBV154 (iNCOVACC®), an Intranasal SARS-CoV-2 Vaccine, Compared with Intramuscular Covaxin® in Healthy Adults: A Randomised, Open-Label, Phase 3 Clinical Trial.”

    Cell: “Intranasal pediatric parainfluenza virus-vectored SARS-CoV-2 vaccine is protective in monkeys.”

    National Institute of Allergy and Infectious Diseases news release: “NIAID Issues Further Awards to Support Pan-Coronavirus Vaccine Development.”

    CEPI news release: “CEPI and DIOSynVax partner in quest to develop broadly protective Betacoronavirus vaccine.” 

    CDC: “Understanding How COVID-19 Vaccines Work.” 

    Nature Immunology: “The T-cell immune response against SARS-CoV-2.”

    National Institutes of Health: “T cells protect against COVID-19 in absence of antibody response.”

    PNAS: “Vaccine-induced systemic and mucosal T cell immunity to SARS-CoV-2 viral variants.”

    Cell Reports: “Pre-existing immunity modulates responses to mRNA boosters.”

    University of Minnesota Center for Infectious Disease Research and Policy: “Coronavirus Vaccines R&D Roadmap.”

    NIH news release: “2NIAID Studies Highlight COVID-10 Natal Vaccine Potential.”

    U.S. Specialty Formulations news release: “Research demonstrates benefits of oral COVID-19 vaccine.” 

     

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  • COVID at 3 Years: Where Are We Headed?

    COVID at 3 Years: Where Are We Headed?

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    March 15, 2023 – Three years after COVID-19 rocked the world, the pandemic has evolved into a steady state of commonplace infections, less frequent hospitalization and death, and continued anxiety and isolation for older people and those with weakened immune systems.

    After about 2½ years of requiring masks in health care settings,  the CDC lifted its recommendation for universal, mandatory masking in hospitals in September 2022,. 

    Some statistics tell the story of how far we have come. COVID-19 weekly cases dropped to nearly 171,000 on March 8, a huge dip from the 5.6 million weekly cases reported in January 2022. COVID-19 deaths, which peaked in January 2021 at more than 23,000 a week, stood at 1,862 per week on March 8.

    Where We Are Now

    Since Omicron is so infectious, “we believe that most people have been infected with Omicron in the world,” says Christopher J.L. Murray, MD, a professor and chair of health metrics sciences at the University of Washington and director of the Institute for Health Metrics and Evaluation in Seattle. Sero-prevalence surveys — or the percentage of people in a population who have antibodies for an infectious disease, or the Omicron variant in this case — support this rationale, he says.

    “Vaccination was higher in the developed world but we see in the data that Omicron infected most individuals in low income countries,” says Murray. For now, he says, the pandemic has entered a “steady state.”

    At New York University Langone Health System, clinical testing is all trending downward, and hospitalizations are low, says Michael S. Phillips, MD, an infectious disease doctor and chief epidemiologist at the health system. 

    In New York City, there has been a shift from pandemic to “respiratory viral season/surge,” he says. 

    The shift is also away from universal source control – where every patient encounter in the system involves masking, distancing, and more – to a focus on the most vulnerable patients “to ensure they’re well-protected,” Phillips says. 

    Johns Hopkins Hospital in Baltimore has seen a “marked reduction” of the number of people coming to the intensive care unit because of COVID, says Brian Thomas Garibaldi, MD, a critical care doctor and director of the Johns Hopkins Biocontainment Unit.

    “That is a testament to the amazing power of vaccines,” he says. 

    The respiratory failures that marked many critical cases of COVID in 2020 and 2021 are much rarer now, a shift that Garibaldi calls “refreshing.”

    “In the past 4 or 5 weeks, I’ve only seen a handful of COVID patients. In March and April of 2020, our entire intensive care unit – in fact, six intensive care units – were filled with COVID patients.”

    Garibaldi sees his own risk differently now as well. 

    “I am not now personally worried about getting COVID, getting seriously ill, and dying from it. But if I have an ICU shift coming up next week, I am worried about getting sick, potentially having to miss work, and put that burden on my colleagues. Everyone is really tired now,” says Garibaldi, who is also an associate professor of medicine and physiology in the Division of Pulmonary and Critical Care Medicine at Johns Hopkins University School of Medicine. 

    What Keeps Experts Up at Night?

    The potential for a stronger SARS-CoV-2 variant to emerge concerns some experts.  

    A new Omicron  subvariant could emerge, or a new variant altogether could arise.  

    One of the main concerns is not just a variant with a different name, but one that can escape current immune protections. If that happens, the new variant could infect people with immunity against Omicron. 

    If we do return to a more severe variant than Omicron, Murray says, “then suddenly we’re in a very different position. 

    Keeping an Eye on COVID-19, Other Viral Illnesses

    We have better genomic surveillance for circulating strains of SARS-CoV-2 than earlier in the pandemic, Phillips says. More reliable, day-to-day data also helped recently with the respiratory syncytial virus (RSV) outbreak and for tracking flu cases.

     Wastewater surveillance as an early warning system for COVID-19 or other respiratory virus surges can be helpful, but more research is needed, Garibaldi says. And with more people testing at home, test positivity rates are likely an undercount. So, hospitalization rates for COVID and other respiratory illnesses remain one of the more reliable community-based measures, for now, at least. 

    One caveat is that sometimes, it is unclear if COVID-19 is the main reason someone is admitted to the hospital vs. someone who comes in for another reason and happens to test positive upon admission. 

    Phillips suggests that using more than one measure might be the best approach, especially to reduce the likelihood of bias associated with any single strategy. “You need to look at a whole variety of tests in order for us to get a good sense of how it’s affecting all communities,” he says. In addition, if a consensus emerges among different measures – wastewater surveillance, hospitalization and test positivity all trending up – “that’s clearly a sign that things are afoot and that we would need to modify our approach accordingly.”

    Where We Could Be Heading

    Murray predicts a steady pace of infection with “no big changes.” But waning immunity remains a concern. 

    That means if you have not had a recent infection – in the last 6 to 10 months – you might want to think about getting a booster, Murray says “The most important thing for people, for themselves, for their families, is to really think about keeping their immunity up.” 

    Phillips hopes the improved surveillance systems will help public health officials make more precise recommendations based on community levels of respiratory illness. 

    When asked to predict what might happen with COVID moving forward, “I can’t tell you how many times I’ve been wrong answering that question,” Garibaldi says.

     Rather than making a prediction, he prefers to focus on hope. 

    “We weathered the winter storm we worried about in terms of RSV, flu, and COVID at the same time. Some places were hit harder than others, especially with pediatric RSV cases, but we haven’t seen anywhere near the level we saw last year and before that,” he says. “So, I hope that continues.”

    “We’ve come very far in just 3 years. When I think about where we were in March 2020 taking care of our first round of COVID patients in our first unit called a biocontainment unit,” Garibaldi says. 

    Murray addresses whether the term “pandemic” still applies at this point. 

    “In my mind, the pandemic is over,” he says, because we are no longer in an emergency response phase. But COVID in some form is likely to be around for a long time, if not forever.  

    “So, it depends on how you define pandemic. If you mean an emergency response, I think we’re out of it. If you mean the formal definition you know of an infection that goes all over the place, then we’re going to be in it for a very long time.”

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  • The COVID Question That Will Take Decades to Answer

    The COVID Question That Will Take Decades to Answer

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    To be a newborn in the year 2023—and, almost certainly, every year that follows—means emerging into a world where the coronavirus is ubiquitous. Babies might not meet the virus in the first week or month of life, but soon enough, SARS-CoV-2 will find them. “For anyone born into this world, it’s not going to take a lot of time for them to become infected,” maybe a year, maybe two, says Katia Koelle, a virologist and infectious-disease modeler at Emory University. Beyond a shadow of a doubt, this virus will be one of the very first serious pathogens that today’s infants—and all future infants—meet.

    Three years into the coronavirus pandemic, these babies are on the leading edge of a generational turnover that will define the rest of our relationship with SARS-CoV-2. They and their slightly older peers are slated to be the first humans who may still be alive when COVID-19 truly hits a new turning point: when almost everyone on Earth has acquired a degree of immunity to the virus as a very young child.

    Read: Is COVID a common cold yet?

    That future crossroads might not sound all that different from where the world is currently. With vaccines now common in most countries and the virus so transmissible, a significant majority of people have some degree of immunity. And in recent months, the world has begun to witness the consequences of that shift. The flux of COVID cases and hospitalizations in most countries seems to be stabilizing into a seasonal-ish sine wave; disease has gotten, on average, less severe, and long COVID seems to be somewhat less likely among those who have recently gotten shots. Even the virus’s evolution seems to be plodding, making minor tweaks to its genetic code, rather than major changes that require another Greek-letter name.

    But today’s status quo may be more of a layover than a final destination in our journey toward COVID’s final form. Against SARS-CoV-2, most little kids have fared reasonably well. And as more babies have been born into a SARS-CoV-2-ridden world, the average age of first exposure to this coronavirus has been steadily dropping—a trend that could continue to massage COVID-19 into a milder disease. Eventually, the expectation is that the illness will reach a stable nadir, at which point it may truly be “another common cold,” says Rustom Antia, an infectious-disease modeler at Emory.

    The full outcome of this living experiment, though, won’t be clear for decades—well after the billions of people who encountered the coronavirus for the first time in adulthood are long gone. The experiences that today’s youngest children have with the virus are only just beginning to shape what it will mean to have COVID throughout a lifetime, when we all coexist with it from birth to death as a matter of course.

    At the beginning of SARS-CoV-2’s global tear, the coronavirus was eager to infect all of us, and we had no immunity to rebuff its attempts. But vulnerability wasn’t just about immune defenses: Age, too, has turned out to be key to resilience. Much of the horror of the disease could be traced to having not only a large population that lacked protection against the virus—but a large adult population that lacked protection against the virus. Had the entire world been made up of grade-schoolers when the pandemic arrived, “I don’t think it would have been nearly as severe,” says Juliet Pulliam, an infectious-disease modeler at Stellenbosch University, in South Africa.

    Across several viral diseases—polio, chicken pox, mumps, SARS, measles, and more—getting sick as an adult is notably more dangerous than as a kid, a trend that’s typically exacerbated when people don’t have any vaccinations or infections to those pathogens in their rearview. The manageable infections that strike toddlers and grade-schoolers may turn serious when they first manifest at older ages, landing people in the hospital with pneumonia, brain swelling, even blindness, and eventually killing some. When scientists plot mortality data by age, many curves bend into “a pretty striking J shape,” says Dylan Morris, an infectious-disease modeler at UCLA.

    The reason for that age differential isn’t always clear. Some of kids’ resilience probably comes from having a young, spry body, far less likely to be burdened with chronic medical conditions that raise severe disease risk. But the quick-wittedness of the young immune system is also likely playing a role. Several studies have found that children are much better at marshaling hordes of interferon—an immune molecule that armors cells against viruses—and may harbor larger, more efficient cavalries of infected-cell-annihilating T cells. That performance peaks sometime around grade school or middle school, says Janet Chou, a pediatrician at Boston Children’s Hospital. After that, our molecular defenses begin a rapid tumble, growing progressively creakier, clumsier, sluggish, and likelier to launch misguided attacks against the tissues that house them. By the time we’re deep into adulthood, our immune systems are no longer sprightly, or terribly well calibrated. When we get sick, our bodies end up rife with inflammation. And our immune cells, weary and depleted, are far less unable to fight off the pathogens they once so easily trounced.

    Whatever the explanations, children are far less likely to experience serious symptoms, or to end up in the hospital or the ICU after being infected with SARS-CoV-2. Long COVID, too, seems to be less prevalent in younger cohorts, says Alexandra Yonts, a pediatrician at Children’s National Hospital. And although some children still develop MIS-C, a rare and dangerous inflammatory condition that can appear weeks after they catch the virus, the condition “seems to have dissipated” as the pandemic has worn on, says Betsy Herold, the chief of pediatric infectious disease at the Children’s Hospital at Montefiore, in the Bronx.

    Should those patterns hold, and as the age of first exposure continues to fall, COVID is likely to become less intense. The relative mildness of childhood encounters with the virus could mean that almost everyone’s first infection—which tends, on average, to be more severe than the ones that immediately follow—could rank low in intensity, setting a sort of ceiling for subsequent bouts. That might make concentrating first encounters “in the younger age group actually a good thing,” says Ruian Ke, an infectious-disease modeler at Los Alamos National Laboratory.

    COVID will likely remain capable of killing, hospitalizing, and chronically debilitating a subset of adults and kids alike. But the hope, experts told me, is that the proportion of individuals who face the worst outcomes will continue to drop. That may be what happened in the aftermath of the 1918 flu pandemic, Antia, of Emory, told me: That strain of the virus stuck around, but never caused the same devastation again. Some researchers suspect that something similar may have even played out with another human coronavirus, OC43: After sparking a devastating pandemic in the 19th century, it’s possible that the virus no longer managed to wreak much more havoc than a common cold in a population that had almost universally encountered it early in life.

    Such a fate for COVID, though, isn’t a guarantee. The virus’s propensity to linger in the body’s nooks and crannies, sometimes causing symptoms that last many months or years, could make it an outlier among its coronaviral kin, says Melody Zeng, an immunologist at Cornell University. And even if the disease is likely to get better than what it is now, that is not a very high bar to clear.

    Some small subset of the population will always be naive to the virus—and it’s not exactly a comfort that in the future, that cohort will almost exclusively be composed of our kids. Pediatric immune systems are robust, UCLA’s Morris told me. But “robust is not the same as infallible.” Since the start of the pandemic, more than 2,000 Americans under the age of 18 have died from COVID—a small fraction of total deaths, but enough to make the disease a leading cause of death for children in the U.S. MIS-C and long COVID may not be common, but their consequences are no less devastating for the children who experience them. Some risks are especially concentrated among our youngest kids, under the age 5, whose immune defenses are still revving up, making them more vulnerable than their slightly older peers. There’s especially little to safeguard newborns just under six months, who aren’t yet eligible for most vaccines—including COVID shots—and who are rapidly losing the antibody-based protection passed down from their mothers while they were in the womb.

    A younger average age of first infection will also probably increase the total number of exposures people have to SARS-CoV-2 in a typical lifetime—each instance carrying some risk of severe or chronic disease. Ke worries the cumulative toll that this repetition could exact: Studies have shown that each subsequent tussle with the virus has the potential to further erode the functioning or structural integrity of organs throughout the body, raising the chances of chronic damage. There’s no telling how many encounters might push an individual past a healthy tipping point.

    Racking up exposures also won’t always bode well for the later chapters of these children’s lives. Decades from now, nearly everyone will have banked plenty of encounters with SARS-CoV-2 by the time they reach advanced age, Chou, from Boston Children’s Hospital, told me. But the virus will also continue to change its appearance, and occasionally escape the immunity that some people built up as kids. Even absent those evasions, as their immune systems wither, many older people may not be able to leverage past experiences with the disease to much benefit. The American experience with influenza is telling. Despite a lifetime of infections and available vaccines, tens of thousands of people typically die annually of the disease in the United States alone, says Ofer Levy, the director of the Precision Vaccines Program at Boston Children’s Hospital. So even with the expected COVID softening, “I don’t think we’re going to reach a point where it’s, Oh well, tra-la-la,” Levy told me. And the protection that immunity offers can have caveats: Decades of research with influenza suggest that immune systems can get a bit hung up on the first versions of a virus that they see, biasing them against mounting strong attacks against other strains; SARS-CoV-2 now seems to be following that pattern. Depending on the coronavirus variants that kids encounter first, their responses and vulnerability to future bouts of illness may vary, says Scott Hensley, an immunologist at the University of Pennsylvania.

    Read: Are our immune systems stuck in 2020?

    Early vaccinations—that ideally target multiple versions of SARS-CoV-2—could make a big difference in reducing just about every bad outcome the virus threatens. Severe disease, long COVID, and transmission to other children and vulnerable adults all would likely be “reduced, prevented, and avoided,” Chou told me. But that’s only if very young kids are taking those shots, which, right now, isn’t at all the case. Nor are they necessarily getting protection passed down during gestation or early life from their mothers, because many adults are not up to date on COVID shots.

    Some of these issues could, in theory, end up moot. A hundred or so years from now, COVID could simply be another common cold, indistinguishable in practice from any other. But Morris points out that this reality, too, wouldn’t fully spare us. “When we bother to look at the burden of the other human coronaviruses, the ones who have been with us for ages? In the elderly, it’s real,” he told me. One study found that a nursing-home outbreak of OC43—the purported former pandemic coronavirus—carried an 8 percent fatality rate; another, caused by NL63, killed three out of the 20 people who caught it in a long-term-care facility in 2017. These and other “mild” respiratory viruses also continue to pose a threat to people of any age who are immunocompromised.

    SARS-CoV-2 doesn’t need to follow in those footsteps. It’s the only human coronavirus against which we have vaccines—which makes the true best-case scenario one in which it ends up even milder than a common cold, because we proactively protect against it. Disease would not need to be as inevitable; the vaccine, rather than the virus, could be the first bit of intel on the disease that kids receive. Tomorrow’s children probably won’t live in a COVID-free world. But they could at least be spared many of the burdens we’re carrying now.

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    Katherine J. Wu

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  • Omicron Much Less Likely to Cause Long COVID, Study Finds

    Omicron Much Less Likely to Cause Long COVID, Study Finds

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    March 10, 2023 – Health care workers infected with the COVID-19 Omicron variant were far less likely to experience significant long COVID symptoms than those who contracted the original SARS-CoV-2 virus, according to new research out of Switzerland.

    The results, which will be presented at the European Congress of Clinical Microbiology & Infectious Diseases conference in April and have been peer reviewed, showed that those infected with the original, “wild-type” virus circulating in the early months of the pandemic still had persistent post-COVID symptoms 18 months later. At the same time, a reinfection with Omicron among this group did not appear to increase their long COVID risks.

    “In a young and healthy population, the risk of long COVID after Omicron infection, independent of vaccination status, is very low,” Philipp Kohler, MD, with the Cantonal Hospital St Gallen and principal investigator of the study, says in an email. 

    “These data suggest that the long COVID wave after Omicron infection will not be as devastating as has been feared by many.”

    The latest findings build on previous research, including an article published in The Lancet, that showed the risk of long COVID was lower with Omicron compared with the Delta variant. Another study published in Nature Communications comparing the same variants also saw lower risks of long-term symptoms with Omicron 3 months after testing positive.

    In the Swiss study, which has yet to be submitted to a medical journal for publication, Kohler and his colleagues tracked 1,201 health care workers from nine domestic health care networks. Their vaccination status was tracked and symptoms were compared with an uninfected control group.

    “Adjusting for this ‘background noise’ is very important because it allows to disentangle the effect of long COVID from other conditions, which are common in the general population and which cause similar symptoms as long COVID, such as fatigue,” Kohler said.

    Health care workers completed online questionnaires three times over the next 2 years to say if they were experiencing any long COVID symptoms as well as how bad their fatigue was. Eighteen symptoms were covered, with loss of smell or taste, tiredness and weakness, burnout and exhaustion, and hair loss the most common issue reported.

    In the study, those who tested positive with the original virus had a 67% higher risk of developing long COVID symptoms when surveyed in March 2021 compared with the control group of participants who remained uninfected. While symptoms declined over time, they were still present 18 months later.

    Meanwhile, the chances of developing long COVID among workers whose first infection was with Omicron did not appear to be greater than those who had never contracted COVID-19, researchers found. The participants’ rates of fatigue were also comparable between the infected and uninfected groups.

    “We can only speculate as to why this was,” Carol Strahm, MD, an infectious disease specialist and one of the researchers involved in the study, said in a statement. She added that it could be due to Omicron being less likely to cause severe illness than the original virus, as well as immunity acquired through previous exposure, including asymptomatic infections that never resulted in the development of antibodies.

    Kohler did note that their sample size was not very large and that the group  studied is not reflective of the broader general population. Older individuals, those with other health issues, and the unvaccinated may not have the same outcomes, he said.

    Linda Geng, MD, co-director of the Post-Acute COVID-19 Syndrome Center at Stanford University, who was not involved in the Swiss study, said while there is research suggesting that long COVID risks may be lower following infections with Omicron compared with earlier variants, she is still seeing many new patients.

    “In our Long COVID clinic, we still see plenty of cases of long COVID that developed after more recent infections,” Geng, who is also a clinical assistant professor of medicine with the university’s Primary Care and Population Health, says in an email.

    “We also don’t know what the future will hold in terms of the evolution of the virus and its impact on long COVID risk. The only guarantee against long COVID is to not get COVID.” 

    Going forward, the Swiss team plans to continue following up with participants to see whether those infected with the original strain are still reporting symptoms nearly three years later.

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  • ‘Breakthrough’ Study: Diabetes Drug Helps Prevent Long COVID

    ‘Breakthrough’ Study: Diabetes Drug Helps Prevent Long COVID

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    March 9, 2023 – Metformin appears to play a role in preventing long COVID when taken early during a COVID-19 infection, according to a new preprint study from The Lancet. The preprint hasn’t yet been peer-reviewed or published in a journal.

    In particular, metformin led to a 42% drop in long COVID among people who had a mild to moderate COVID-19 infection. 

    “Long COVID affects millions of people, and preventing long COVID through a treatment like metformin could prevent significant disruptions in people’s lives,” says lead author Carolyn Bramante, MD, an assistant professor of internal medicine and pediatrics at the University of Minnesota.

    Between January 2021 and February 2022, Bramante and colleagues tested three oral medications – metformin (typically used to treat type 2 diabetes), ivermectin (an antiparasitic), and fluvoxamine (an antidepressant) – in a clinical trial across the U.S. called COVID-OUT. The people being studied, investigators, care providers, and others involved in the study were blinded to the randomized treatments. The trial was decentralized, with no in-person contact with participants.

    The researchers included patients who were ages 30-85 with overweight or obesity, had documentation of a confirmed COVID-19 infection, had fewer than 7 days of symptoms, had no known prior infection, and joined the study within 3 days of their positive test. The study included monthly follow-up for 300 days, and participants indicated whether they received a long COVID diagnosis from a medical doctor, which the researchers confirmed in medical records after participants gave consent.

    The medications were pre-packaged into pill boxes for fast delivery to participants and to ensure they took the correct number of each type of pill. The packages were sent via same-day courier or overnight shipping.

    The metformin doses were doled out over 14 days: with 500 milligrams on the first day, 500 milligrams twice a day for the next 4 days, and then 500 milligrams in the morning and 1,000 milligrams in the evening for the remaining 9 days.

    Among the 1,323 people studied, 1,125 agreed to do long-term follow-up for long COVID, including 564 in the metformin group and 561 in the blinded placebo group. The average age was 45, and 56% were women, including 7% who were pregnant. 

    The average time from the start of symptoms to starting medication was 5 days, and 47% began taking the drug within 4 days or less. About 55% had received the primary COVID-19 vaccination series, including 5.1% who received an initial booster, before enrolling in the study.

    Overall, 8.4% of participants reported that a medical provider diagnosed them with long COVID. Of those who took metformin, 6.3% developed long COVID, compared to 10.6% among those who took the identical-matched placebo.

    The risk reduction for metformin was 42% versus the placebo, which was consistent across subgroups, including vaccination status and different COVID-19 variants.

    When metformin was started less than 4 days after COVID-19 symptoms started, the effect was potentially even greater, with a 64% reduction, as compared with a 36% reduction among those who started metformin after 4 or more days after symptoms.

    Neither ivermectin nor fluvoxamine showed any benefits for preventing long COVID.

    At the same time, the study authors caution that more research is needed. 

    “The COVID-OUT trial does not indicate whether or not metformin would be effective at preventing long COVID if started at the time of emergency department visit or hospitalization for COVID-19, nor whether metformin would be effective as treatment in persons who already have long COVID,” they wrote. “With the burden of long COVID on society, confirmation is urgently needed in a trial that addresses our study’s limitations in order to translate these results into practice and policy.”

    Several risk factors for long COVID emerged in the analysis. About 11.1% of the women had a long COVID diagnosis, as compared with 4.9% of the men. Also, those who had received at least the primary vaccine series had a lower risk of developing long COVID, at 6.6%, as compared with 10.5% among the unvaccinated. Only one of the 57 people who received a booster shot developed long COVID.

    Notably, pregnant and lactating people were included in this study, which is important given that pregnant people face higher risks for poor COVID-19 outcomes and are excluded from most non-obstetric clinical trials, the study authors wrote. In this study, they were randomized to metformin or placebo but not ivermectin or fluvoxamine due to limited research about the safety of those drugs during pregnancy and lactation.

    The results are now under journal review but show consistent findings from other recent studies. Also, in August 2022, the authors published results from COVID-OUT that showed metformin led to a 42% reduction in hospital visits, emergency department visits, and deaths related to severe COVID-19.

    “Given the lack of side effects and cost for a 2-week course, I think these data support use of metformin now,” says Eric Topol, MD, founder and director of the Scripps Research Translational Institute and editor-in-chief of Medscape, WebMD’s sister site for health care professionals. 

    Topol, who wasn’t involved with this study, has been a leading voice on COVID-19 research throughout the pandemic. He noted the need for more studies, including a factorial design trial to test metformin and Paxlovid, which has shown promise in preventing long COVID. Topol also wrote about the preprint in Ground Truths, his online newsletter.

    “As I’ve written in the past, I don’t use the term ‘breakthrough’ lightly,” he wrote. “But to see such a pronounced benefit in the current randomized trial of metformin, in the context of it being so safe and low cost, I’d give it a breakthrough categorization.”

    Another way to put it, Topol wrote, is that based on this study, he himself would take metformin if he became infected with COVID-19. 

    Jeremy Faust, MD, an emergency medicine doctor at Brigham and Women’s Hospital in Boston, also wrote about the study in his newsletter, Inside Medicine. He noted that the 42% reduction in long COVID means that 23 COVID-19 patients need to be treated with metformin to prevent one long COVID diagnosis, which is an “important reduction.”

    “Bottom line: If a person who meets criteria for obesity or overweight status were to ask me if they should take metformin (for 2 weeks) starting as soon as they learn they have COVID-19, I would say yes in many if not most cases, based on this new data,” he wrote. “This is starting to look like a real win.”

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  • Long COVID Takes Toll on Already Stretched Health Care Workforce

    Long COVID Takes Toll on Already Stretched Health Care Workforce

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    March 6, 2023 — The impact of long COVID – and its sometimes-disabling symptoms that can persist for more than a year — has worsened health care’s already severe workforce shortage. 

    Hospitals have turned to training programs, traveling nurses, and emergency room staffing services. While the shortage of clinical workers continues, support workers are also in short supply, with no end in sight.

    “Our clinical staff is the front line, but behind them, several layers of people do jobs that allow them to do their jobs,” says Joanne Conroy, MD, president of Dartmouth-Hitchcock Medical Center, a 400-bed hospital in New Hampshire. “Lab and radiology and support people and IT and facilities and housekeeping … the list goes on and on.” 

    Long COVID is contributing to the U.S. labor shortage overall, according to research. But with no test for the condition and a wide range of symptoms and severity – and with some workers attributing their symptoms to something else — it’s difficult to get a clear picture of the impacts on the health care system.

    Emerging research suggests long COVID is hitting the health care system particularly hard.

     The system has lost 20% of its workforce over the course of the pandemic, with hospital understaffing at hospitals resulting in burnout and fatigue among frontline medical professionals, according to the U.S. Bureau of Labor Statistics.

    Other research spotlights the significant impacts on health care workers:

    • In New York, nearly 20% of long COVID patients are still out of work after a year, with high numbers among health care workers, according to a new study of workers compensation claims.  
    • A new study in the American Journal of Infection Control reports nurses in intensive care units and non-clinical workers are especially vulnerable. About 2% of nurses have not returned work after developing COVID-19, according to a 2022 survey by the National Nursing Association, which represents unionized workers.  
    • In the United Kingdom, long COVID symptoms impact the lives of 1.5 million people, according to the Office of National Statistics, which is monitoring the impact of COVID. Nearly 20% report their ability to engage in day-to-day activities had been “limited a lot,” according to data from February.

    While long COVID brain fog, fatigue, and other symptoms can sometimes last just a few weeks or months, a percentage of those who develop the condition – on or off the job – go on to have chronic, long-lasting, disabling symptoms that may linger for years. 

    Several recent research studies suggest the impacts of long COVID on health care workers, who interact more closely with COVID patients than others on the job, are greater than other occupations and are likely to have a continuing impact.

    About 25% of those filing COVID-related workers compensation claims for lost time at work are health care workers, according to a study from the National Council on Compensation Insurance. That was more than any other industry. At the same time,  the study – which included data from nine states – found that worker compensation claims for acute COVID cases dropped from 11% in 2020 to 4% in 2021.  

    Last year, Katie Bach wrote a study for the Brookings Institution on the impact of long COVID on the labor market. She said in an email that she still thinks it’s a problem for the health care workforce and the workforce in general. 

    “It is clear that we have a persistent group of long COVID patients who aren’t getting better,” she says.

    Hospitals Forced to Adapt

    Dartmouth-Hitchcock Medical Center is the largest health system — and one of the largest employers — in New Hampshire with 400 beds and 1,000 employees at the flagship hospital and affiliate. Human resource staff here have been tracking COVID-19 infections among employees.

    The hospital is treating fewer COVID cases, down from a high of about 500 a month to between 100 and 200 cases month. But at the same time, they are seeing an increase in staff are who calling in sick with a range of COVID-like symptoms or consulting with the occupational medicine department, says Aimee M. Claiborne, the head of human resources for the Dartmouth Health system. 

    “Some of that might be due to long COVID; some if it might be due to flu or RSV or other viruses,” she says. “We are definitely looking at things like absenteeism and what people are calling in for.”

    They are also looking at “presenteeism” – where workers show up when they are not feeling well and they are not as productive, she says. 

    Those who return to work can access the company’s existing disability programs to get accommodations – allowing people with low energy or fatigue or another disability to, for example, work shorter shifts or from home. Dartmouth-Hitchcock is also building more remote work into its system after trying the approach during the height of the pandemic, Claiborne says. 

    Ultimately, some workers will not be able to return to work. Those who were infected on the job can also seek workers’ compensation, but coverage varies from employer to employer and state to state. 

    On the other side of the country, Annette Gillaspie, a nurse in a small Oregon hospital, says she caught COVID – like many other health care workers – early in the pandemic before vaccines were available and protective measure were in place. 

    She says she still hasn’t fully recovered 3 years later – she still has a cough as well as POTS (postural orthostatic tachycardia syndrome), a common post-COVID-19 condition of the automatic nervous system that can cause dizziness and fatigue when a sitting person stands up.

    But she’s back at work and the hospital has made accommodations for her, like a parking space closer to the building. 

    She remembers being exposed — she forgot to put on protective glasses. A few days later she was in bed with COVID. She says she never quite recovered. Gillaspie says she sees a lot of other people at work who seem to have some long COVID symptoms. 

    “Some of them know it’s COVID related,” she says. “They’re doing just like I do — pushing through.”

    They do it because they love their work, she says. 

    Shortages Span the Country

    Millions of people are living in what the federal government calls “health practitioner shortage areas” without enough dental, primary, and mental health practitioners. At hospitals, vacancies for nurses and respiratory therapists went up 30% between 2019 and 2020, according to an American Hospital Association (AHA) survey. 

    Hospitals will need to hire to 124,000 doctors and at least 200,000 nurses per year to meet increased demand and to replace retiring nurses, according to the AHA. 

    When the pandemic hit, hospitals had to bring expensive traveling nurses in to deal with the shortages driven by wave after wave of COVID surges. But as the AHA notes, the staffing shortfalls in health care existed before the pandemic.

    The federal government, states, and health care systems have programs to address the shortage. Some hospitals train their own staff, while others may be looking at expanding the “scope of care” for existing providers, like physician assistants. Still others are looking to support existing staff who may be suffering from burnout and fatigue – and now, long COVID.

    Long COVID numbers  — like the condition itself — are hard to measure and ever-changing. Between 10% and 11% of those who have had COVID have long COVID, according to the Household Pulse Survey, an ongoing Census Bureau data project.

    A doctor in the U.K. recently wrote that she and others initially carried on working, believing they could push through symptoms. 

    “As a doctor, the system I worked in and the martyr complex instilled by medical culture enabled that view. In medicine, being ill, being human, and looking after ourselves is still too often seen as a kind of failure or weakness,” she wrote anonymously in February in the journal BMJ.

    Jeffrey Siegelman, MD, a doctor at Emory University Medical Center in the Atlanta, also wrote a journal article about his experiences with long COVID in 2020 in JAMA. More than 2 years later, he still has long COVID. 

    He was out of work for 5 months, returned to practice part-time, and was exempt from night work – “a big ask,” he says, for an emergency department doctor. 

    In general,  he feels like the hospital “bent over backwards” to help him get back to work. He is just about to return to work full-time with accommodations.

    “I’ve been really lucky in this job,” Siegelman says. “That’s not what most patients with long COVID deal with.”

    He led a support group for hospital employees who had long COVID – including clerks, techs, nurses, and doctors. Many people were trying to push through their symptoms to do their jobs, he says. A couple of people who ran through their disability coverage were dismissed.

    He acknowledges that as a doctor, he had better disability coverage than others. But with no diagnostic test to confirm long COVID, he’s not exempt from self-doubt and stigma. 

    Siegelman was one of the doctors who questioned the physiological basis for ME/CFS (myalgic encephalomyelitis/chronic fatigue syndrome), a condition that mirrors long COVID and commonly appears in those who have lingering symptoms of an infection. He doesn’t anymore. 

    Researchers are beginning to link ME/CFS and other long-term problems to COVID and other infections, and research is underway to better understand what is known as post-infection illnesses. 

    Hospitals are dealing with so much, Siegelman says, that he understands if there’s a hesitancy to acknowledge that people are working at a reduced capacity. 

    “It’s important for managers in hospitals to talk about this with their employees and allow people to acknowledge if they are taking more time than expected to recover from an illness,” he says. 

    In medicine, he says, you are expected to show up for work unless you are on a gurney yourself. Now, people are much more open to calling in if they have a fever – a good development, he says.

    And while he prepared to return to work, symptoms linger. 

    “I can’t taste still,” he says. “That’s a pretty constant reminder that there is something real going on here.” 

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  • Even Mild COVID Might Change Your Brain

    Even Mild COVID Might Change Your Brain

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    By Cara Murez 

    HealthDay Reporter

    TUESDAY, Feb. 21, 2023 (HealthDay News) — People who are experiencing anxiety and depression months after a mild case of COVID-19 may have changes affecting the structure and function of their brains, Brazilian researchers report.

    “There is still much to learn about long COVID, which includes a wide range of health problems, including anxiety and depression, months after infection,” said Dr. Clarissa Yasuda of the University of Campinas in São Paulo.

    “Our findings are concerning, as even people with a mild case of COVID-19 are showing changes in their brains months later. More studies are needed to hopefully identify treatments to prevent any long-term effects on people’s quality of life,” she added.

    To understand this, the researchers studied 254 people who had a mild COVID-19 infection. On average, the patients were 41 years old and had COVID-19 three months earlier.

    Each participant completed tests of anxiety or depression symptoms and had brain scans.

    In all, 102 people had symptoms of both anxiety and depression and 152 people had none, the investigators found.

    The researchers then looked for evidence of shrinkage in the brain’s gray matter. Scans were compared with those of 148 people who had not had COVID-19.

    Those who had COVID-19 and were experiencing anxiety and depression had shrinkage in the limbic area of the brain, which is involved in memory and emotional processing. Those who had no symptoms of anxiety and depression after COVID-19 had no brain shrinkage, the study authors said.

    Using a special type of software to analyze networks with resting-state brain activity, the researchers also looked at brain function and changes in connectivity between areas of the brain.

    They did this in 84 people from the group with no symptoms; 70 people from the anxiety and depression group; and 90 people who did not have COVID-19. The researchers found widespread functional changes in each of the 12 networks they tested in the group with anxiety and depression symptoms.

    The COVID group without symptoms also had changes, but in five rather than 12 networks.

    “Our results suggest a severe pattern of changes in how the brain communicates as well as its structure, mainly in people with anxiety and depression with long COVID syndrome, which affects so many people,” Yasuda said in a news release from the American Academy of Neurology. “The magnitude of these changes suggests that they could lead to problems with memory and thinking skills, so we need to be exploring holistic treatments even for people mildly affected by COVID-19.”

    The findings were made public Feb. 20 in advance of their presentation in Boston and online at an American Academy of Neurology meeting April 22 to 27.

    Research presented at meetings should be considered preliminary until published in a peer-reviewed journal.

     

    More information

    The U.S. Centers for Disease Control and Prevention has more on long COVID.

     

    SOURCE: American Academy of Neurology, news release, Feb. 20, 2023

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