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Tag: long COVID

  • Vaccination Could Reduce Risk of Long COVID, Study Shows

    Vaccination Could Reduce Risk of Long COVID, Study Shows

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    Feb. 15, 2023 – After studying thousands of people’s symptoms post-COVID-19, researchers have found that getting vaccinated could potentially reduce the risk of long COVID. 

    The new study – which looked at patients 3 months after their COVID-19 infections across pre-Delta, Delta, and Omicron variants – at first saw that long COVID symptoms were more common in the pre-Delta period than in the Delta and Omicron periods. But these differences across variants became less important when researchers adjusted for vaccination status, suggesting that the vaccine could play a key role in lessening the risk of long COVID and making its symptoms less severe. 

    Another important finding of the study, from researchers at Chicago’s Rush University Medical Center and the University of California San Francisco and published in the journal Clinical Infectious Diseases, was the sheer number of people post-COVID-19 who reported severe fatigue. 

    “Mild fatigue is much different than severe, life-impacting fatigue,” lead author Michael Gottlieb, MD, said at a media briefing Wednesday. “One in eight affected with COVID had severe, prolonged fatigue at 3 months. … That speaks to the impact we’re seeing as a society.” 

    The study included 2,402 COVID-positive and 821 COVID-negative people, with 463 falling into the pre-Delta category, 1,198 during Delta, and 741 during Omicron. 

    The authors did not weigh how severe the  patients’ initial COVID infections were versus their prolonged symptoms, but Gottlieb told reporters that the group is currently working on supplemental survey research to see if there are any parallels between the two. 

    Gottlieb said the research team is continuing to follow patients beyond the 3-month mark, to see what the paths of their symptoms look like. Some early data, he said, shows patients’ symptoms going in both directions: Some people who have minimal symptoms at 3 months might convert to severe symptoms at 6 months, and others with severe symptoms at 3 months might be better at 6 months. 

    All of these lingering questions, including how reinfection plays into long COVID, will be the focus of future research for Gottlieb’s team. 

    “We need to understand long COVID better, and we need to define it better,” Gottlieb said. “Long COVID isn’t a singular concept, there are different phenotypes and versions of it. As researchers, public health leaders, and as a society, we need to better understand what people are going through.” 

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  • The Future of Long COVID

    The Future of Long COVID

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    In the early spring of 2020, the condition we now call long COVID didn’t have a name, much less a large community of patient advocates. For the most part, clinicians dismissed its symptoms, and researchers focused on SARS-CoV-2 infections’ short-term effects. Now, as the pandemic approaches the end of its third winter in the Northern Hemisphere, the chronic toll of the coronavirus is much more familiar. Long COVID has been acknowledged by prominent experts, national leaders, and the World Health Organization; the National Institutes of Health has set up a billion-dollar research program to understand how and in whom its symptoms unfurl. Hundreds of long-COVID clinics now freckle the American landscape, offering services in nearly every state; and recent data hint that well-vetted drugs to treat or prevent long COVID may someday be widespread. Long COVID and the people battling it are commanding more respect, says Hannah Davis, a co-founder of the Patient-Led Research Collaborative, who has had long COVID for nearly three years: Finally, many people “seem willing to understand.”

    But for all the ground that’s been gained, the road ahead is arduous. Long COVID still lacks a universal clinical definition and a standard diagnosis protocol; there’s no consensus on its prevalence, or even what symptoms fall under its purview. Although experts now agree that long COVID does not refer to a single illness, but rather is an umbrella term, like cancer, they disagree on the number of subtypes that fall within it and how, exactly, each might manifest. Some risk factors—among them, a COVID hospitalization, female sex, and certain preexisting medical conditions—have been identified, but researchers are still trying to identify others amid fluctuating population immunity and the endless slog of viral variants. And for people who have long COVID now, or might develop it soon, the interventions are still scant. To this day, “when someone asks me, ‘How can I not get long COVID?’ I can still only say, ‘Don’t get COVID,’” says David Putrino, a neuroscientist and physical therapist who leads a long-COVID rehabilitation clinic at Mount Sinai’s Icahn School of Medicine.

    As the world turns its gaze away from the coronavirus pandemic, with country after country declaring the virus “endemic” and allowing crisis-caliber interventions to lapse, long-COVID researchers, patients, and activists worry that even past progress could be undone. The momentum of the past three years now feels bittersweet, they told me, in that it represents what the community might lose. Experts can’t yet say whether the number of long-haulers will continue to increase, or offer a definitive prognosis for those who have been battling the condition for months or years. All that’s clear right now is that, despite America’s current stance on the coronavirus, long COVID is far from being beaten.

    Despite an influx of resources into long-COVID research in recent months, data on the condition’s current reach remain a mess—and scientists still can’t fully quantify its risks.

    Recent evidence from two long-term surveys have hinted that the pool of long-haulers might be shrinking, even as new infection rates remain sky-high: Earlier this month, the United Kingdom’s Office for National Statistics released data showing that 2 million people self-reported lingering symptoms at the very start of 2023, down from 2.3 million in August 2022. The U.S. CDC’s Household Pulse Survey, another study based on self-reporting, also recorded a small drop in long-COVID prevalence in the same time frame, from about 7.5 percent of all American adults to roughly 6. Against the massive number of infections that have continued to slam both countries in the pandemic’s third year and beyond, these surveys might seem to imply that long-haulers are leaving the pool faster than newcomers are arriving.

    Experts cautioned, however, that there are plenty of reasons to treat these patterns carefully—and to not assume that the trends will be sustained. It’s certainly better that these data aren’t showing a sustained, dramatic uptick in long-COVID cases. But that doesn’t mean the situation is improving. Throughout the pandemic, the size of the long-COVID pool has contracted or expanded for only two reasons: a change in the rate at which people enter, or at which they exit. Both figures are likely to be in constant flux, as surges of infections come and go, masking habits change, and vaccine and antiviral uptake fluctuates. Davis pointed out that the slight downward tick in both studies captured just a half-year stretch, so the downward slope could be one small portion of an undulating wave. A few hours spent at the beach while the tide is going out wouldn’t be enough to prove that the ocean is drying up.

    Read: We’re bungling the COVID wind-down

    Recent counts of new long-COVID cases might also be undercounts, as testing slows and people encounter more challenges getting diagnosed. That said, it’s still possible that, on a case-by-case basis, the likelihood of any individual developing long COVID after a SARS-CoV-2 infection may have fallen since the pandemic’s start, says Deepti Gurdasani, a clinical epidemiologist at Queen Mary University of London and the University of New South Wales. Population immunity—especially acquired via vaccination—has, over the past three years, better steeled people’s bodies against the virus, and strong evidence supports the notion that vaccines can moderately reduce the risk of developing long COVID. Treatments and behavioral interventions that have become more commonplace may have chipped away at incidence as well. Antivirals can now help to corral the virus early in infection; ventilation, distancing, and masks—when they’re used—can trim the amount of virus that infiltrates the body. And if overall exposure to the virus can influence the likelihood of developing long COVID, that could help explain why so many debilitating cases arose at the very start of the pandemic, when interventions were few and far between, says Steven Deeks, a physician researcher at UC San Francisco.

    There’s not much comfort to derive from those individual-level stats, though, when considering what’s happening on broader scales. Even if immunity makes the average infected person less likely to fall into the long-COVID pool, so many people have been catching the virus that the inbound rate still feels like a flood. “The level of infection in many countries has gone up substantially since 2021,” Gurdasani told me. The majority of long-COVID cases arise after mild infections, the sort for which our immune defenses fade most rapidly. Now that masking and physical distancing have fallen by the wayside, people may be getting exposed to higher viral doses than they were a year or two ago. In absolute terms, then, the number of people entering the long-COVID pool may not really be decreasing. Even if the pool were getting slightly smaller, its size would still be staggering, an ocean of patients with titanic needs. “Anecdotally, we still have an enormous waitlist to get into our clinic,” Putrino told me.

    Deeks told me that he’s seen another possible reason for optimism: People with newer cases of long COVID might be experiencing less debilitating or faster-improving disease, based on what he’s seen. “The worst cases we’ve seen come from the first wave in 2020,” he said. But Putrino isn’t so sure. “If you put an Omicron long-COVID patient in front of me, versus one from the first wave, I wouldn’t be able to tell you who was who,” he said. The two cases would also be difficult to compare, because they’re separated by so much time. Long COVID’s symptoms can wax, wane, and qualitatively change; a couple of years into the future, some long-haulers who’ve just developed the condition may be in a spot that’s similar to where many veterans with the condition are now.

    Read: The flu-ification of COVID policy is almost complete

    Experts’ understanding of how often people depart the long-COVID pool is also meager. Some long-haulers have undoubtedly seen improvement—but without clear lines distinguishing short COVID from medium and long COVID, entry and exit into these various groups is easy to over- or underestimate. What few data exist on the likelihood of recovery or remission is inconsistent, and not always rosy: Investigators of RECOVER, a large national study of long COVID, have calculated that about two-thirds of the long-haulers in their cohort do not return to baseline health. Putrino, who has worked with hundreds of long-haulers since the pandemic began, estimates that although most of his patients experience at least some benefit from a few months of rehabilitation, only about one-fifth to one-quarter of them eventually reach the point of feeling about as well as they did before catching the virus, while the majority hit a middling plateau. A small minority of the people he has treated, he told me, never seem to improve at all.

    Letícia Soares, a long-hauler in Brazil who caught the virus near the start of the pandemic, falls into that final category. Once a disease ecologist who studied parasite transmission in birds, she is now mostly housebound, working when she is able as a researcher for the Patient-Led Research Collaborative. Her days revolve around medications and behavioral modifications she uses for her fatigue, sleeplessness, and chronic pain. Soares no longer has the capacity to cook or frequently venture outside. And she has resigned herself to this status quo until the treatment landscape changes drastically. It is not the life she pictured for herself, Soares told me. “Sometimes I think the person I used to be died in April of 2020.”

    Even long-haulers who have noticed an improvement in their symptoms are wary of overconfidence. Some absolutely do experience what could be called recovery—but for others, the term has gotten loaded, almost a jinx. “If the question is, ‘Are you doing the things you were doing in 2019?’ the answer is largely no,” says JD Davids, a chronic-illness advocate based in New York. For some, he told me, “getting better” has been more defined by a resetting of expectations than a return to good health. Relapses are also not uncommon, especially after repeat encounters with the virus. Lisa McCorkell, a long-hauler and a co-founder of the Patient-Led Research Collaborative, has felt her symptoms partly abate since she first fell ill in the spring of 2020. But, she told me, she suspects that her condition is more likely to deteriorate than further improve—partly because of “how easy it is to get reinfected now.”

    Last week, in his State of the Union address, President Joe Biden told the American public that “we have broken COVID’s grip on us.” Highlighting the declines in the rates of COVID deaths, the millions of lives saved, and the importance of remembering the more than 1 million lost, Biden reminded the nation of what was to come: “Soon we’ll end the public-health emergency.”

    When the U.S.’s state of emergency was declared nearly three years ago, as hospitals were overrun and morgues overflowed, the focus was on severe, short-term disease. Perhaps in that sense, the emergency is close to being over, Deeks told me. But long COVID, though slower to command attention, has since become its own emergency, never formally declared; for the millions of Americans who have been affected by the condition, their relationship with the virus does not yet seem to be in a better place.

    Read: Trying to stop long COVID before it even starts

    Even with many more health-care providers clued into long COVID’s ills, the waiting lists for rehabilitation and treatment remain untenable, Hannah Davis told me. “I consider myself someone who gets exceptional care compared to other people,” she said. “And still, I hear from my doctor every nine or 10 months.” Calling a wrap on COVID’s “emergency” phase could worsen that already skewed supply-demand ratio. Changes to the nation’s funding tactics could strip resources—among them, access to telehealth; Medicaid coverage; and affordable antivirals, tests, and vaccines—from vulnerable populations, including people of color, that aren’t getting their needs met even as things stand, McCorkell told me. And as clinicians internalize the message that the coronavirus has largely been addressed, attention to its chronic impacts may dwindle. At least one of the country’s long-COVID clinics has, in recent months, announced plans to close, and Davis worries that more could follow soon.

    Scientists researching long COVID are also expecting new challenges. Reduced access to testing will complicate efforts to figure out how many people are developing the condition, and who’s most at risk. Should researchers turn their scientific focus away from studying causes and cures for long COVID when the emergency declaration lifts, Davids and others worry that there will be ripple effects on the scientific community’s interest in other, neglected chronic illnesses, such as ME/CFS (myalgic encephalomyelitis or chronic fatigue syndrome), a diagnosis that many long-haulers have also received.

    The end of the U.S.’s official crisis mode on COVID could stymie research in other ways as well. At Johns Hopkins University, the infectious-disease epidemiologists Priya Duggal, Shruti Mehta, and Bryan Lau have been running a large study to better understand the conditions and circumstances that lead to long COVID, and how symptoms evolve over time. In the past two years, they have gathered online survey data from thousands of people who both have and haven’t been infected, and who have and haven’t seen their symptoms rapidly resolve. But as of late, they’ve been struggling to recruit enough people who caught the virus and didn’t feel their symptoms linger. “I think that the people who are suffering from long COVID will always do their best to participate,” Duggal told me. That may not be the case for individuals whose experiences with the virus were brief. A lot of them “are completely over it,” Duggal said. “Their life has moved on.”

    Kate Porter, a Massachusetts-based marketing director, told me that she worries about her family’s future, should long COVID fade from the national discourse. She and her teenage daughter both caught the virus in the spring of 2020, and went on to develop chronic symptoms; their experience with the disease isn’t yet over. “Just because the emergency declaration is expiring, that doesn’t mean that suddenly people are magically going to get better and this issue is going to go away,” Porter told me. After months of relative improvement, her daughter is now fighting prolonged bouts of fatigue that are affecting her school life—and Porter isn’t sure how receptive people will be to her explanations, should their illnesses persist for years to come. “Two years from now, how am I going to explain, ‘Well, this is from COVID, five years ago’?” she said.

    A condition that was once mired in skepticism, scorn, and gaslighting, long COVID now has recognition—but empathy for long-haulers could yet experience a backslide. Nisreen Alwan, a public-health researcher at the University of Southampton, in the U.K., and her colleagues have found that many long-haulers still worry about disclosing their condition, fearing that it could jeopardize their employment, social interactions, and more. Long COVID could soon be slated to become just one of many neglected chronic diseases, poorly understood and rarely discussed.

    Davis doesn’t think that marginalization is inevitable. Her reasoning is grim: Other chronic illnesses have been easier to push to the sidelines, she said, on account of their smaller clinical footprint, but the pool of long-haulers is enormous—comprising millions of people in the U.S. alone. “I think it’s going to be impossible to ignore,” she told me. One way or another, the world will have no choice but to look.

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    Katherine J. Wu

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  • Inflammation and Immunity Troubles Top Long COVID Suspect List

    Inflammation and Immunity Troubles Top Long COVID Suspect List

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    SOURCES:

    Alexander Truong, MD, pulmonologist, assistant professor, Emory University School of Medicine, Atlanta.

    Alexander Charney, MD, PhD, lead principal investigator, RECOVER adult cohort, associate professor of psychiatry, genetics and genomic sciences, neuroscience, and neurosurgery, Icahn School of Medicine at Mount Sinai, New York.

    Michael Peluso, MD, assistant professor of medicine, infectious diseases doctor, University of California, San Francisco.

    Rainu Kaushal, MD, senior associate dean for clinical research, Weill Cornell Medicine, New York.

    The Lancet eClinicalMedicine: “Characterizing long COVID in an international cohort: 7 months of symptoms and their impact.”

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

    Immunity, Inflammation and Disease: “COVID-19 associated EBV reactivation and effects of ganciclovir treatment.”

    Clinical Infectious Diseases: “Persistent Circulating Severe Acute Respiratory Syndrome Coronavirus 2 Spike Is Associated With Post-acute Coronavirus Disease 2019 Sequelae.”

    Cell Reports Medicine: “The IL-1β, IL-6, and TNF cytokine triad is associated with post-acute sequelae of COVID-19.”

    Nature Medicine: “Data-driven identification of post-acute SARS-CoV-2 infection subphenotypes,” “Molecular states during acute COVID-19 reveal distinct etiologies of long-term sequelae.”

    Nature Immunology: “Immunological dysfunction persists for 8 months following initial mild-to-moderate SARS-CoV-2 infection.”

    Science Translational Medicine: “Persistent post–COVID-19 smell loss is associated with immune cell infiltration and altered gene expression in olfactory epithelium.”

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

    Journal of Medical Virology: “Persistence of neutrophil extracellular traps and anticardiolipin auto-antibodies in post-acute phase COVID-19 patients.”

    Johns Hopkins Medicine: “What are common symptoms of autoimmune disease?”

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  • Long COVID Affecting More Than One Third of College Students, Faculty

    Long COVID Affecting More Than One Third of College Students, Faculty

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    Jan. 27, 2023 —  Almost 36% of students and faculty at George Washington University with a history of COVID-19 reported symptoms consistent with long COVID in a new study. 

    With a median age of 23 years, the study is unique for evaluating mostly healthy, young adults and for its rare look at long COVID in a university community. 

    The more symptoms during a bout with COVID,  the greater the risk for long COVID, the researchers found. That lines up with previous studies. Also, the more vaccinations and booster shots against SARS-CoV-2, the virus that causes COVID, the lower the long COVID risk. 

    Women were more likely than men to be affected. Current or prior smoking, seeking medical care for COVID, and receiving antibody treatment also were linked to higher chances for developing long COVID. 

    Lead author Megan Landry, DrPH, MPH, and colleagues were already assessing students, staff, and faculty at George Washington University in Washington, DC, who tested positive for COVID. Then they started seeing symptoms that lasted 28 days or more after their 10-day isolation period. 

    “We were starting to recognize that individuals … were still having symptoms longer than the typical isolation period,” says Landry. So they developed a questionnaire to figure out the how long these symptoms last and how many people are affected by them. 

    The list of potential symptoms was long and included trouble thinking, fatigue, loss of smell or taste, shortness of breath, and more. 

    The study was published online Thursday in the CDC’s Emerging Infectious Diseases journal. Results are based on records and responses from 1,388 students, faculty, and staff from July 2021 to March 2022.

    People had a median of four long COVID symptoms, about 63% were women, and 56% were non-Hispanic white. About three-quarters were students and the remainder were faculty and staff. 

    The finding that 36% of people with a history of COVID reported long COVID symptoms did not surprise Landry.

    “Based on the literature that’s currently out there, it ranges from a 10% to an 80% prevalence of long COVID,” she says. “We kind of figured that we would fall somewhere in there.”

    In contrast, that figure seemed high to Eric Topol, MD, editor-in-chief ofMedscape, WebMD’s sister site for health care professionals.

    “That’s really high,” says Topol, who is also founder and director of the Scripps Research Translational Institute in La Jolla, CA. Topol says most studies estimate that about 10% of people with a history of acute infection develop long COVID. 

    Even at 10%, which could be an underestimate, that’s a lot of affected people globally. 

    “At least 65 million individuals around the world have long COVID, based on a conservative estimated incidence of 10% of infected people and more than 651 million documented COVID-19 cases worldwide; the number is likely much higher due to many undocumented cases,” Topol and colleagues write in a long COVID review article published earlier this month in Nature Reviews Microbiology. 

    Topol agrees the study is unique in evaluating younger adults. Long COVID is much more common in middle-age people, those in their 30s and 40s, rather than students, he says. 

    About 30% of study participants were fully vaccinated with an initial vaccine series, 42% had received a booster dose, and 29% were not fully vaccinated at the time of their first positive test for COVID. Those who were not fully vaccinated were significantly more likely to report symptoms of long COVID. 

    “I know a lot of people wish they could put COVID on the back burner or brush it under the rug, but COVID is still a real thing. We need to continue supporting vaccines and boosters and make sure people are up to date. Not only for COVID, but for flu as well.” 

    Research Continues

    “Long COVID is still evolving and we continue to learn more about it every day,” Landry says. “It’s just so new and there are still a lot of unknowns. That’s why it’s important to get this information out.” 

    People with long COVID often have a hard time with occupational, educational, social, or personal activities compared to before COVID, with effects that can last for more than 6 months, the authors note. 

    “I think across the board, universities in general need to consider the possibility of folks on their campuses are having symptoms of long COVID,” Landry says.

    Moving forward, Landry and colleagues would like to continue investigating long COVID. For example, in the current study, they did not ask about severity of symptoms or how the symptoms affected daily functioning. 

    “I would like to continue this and dive deeper into how disruptive their symptoms of long COVID are to their everyday studying, teaching, or their activities to keeping a university running,” Landry says. 

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  • Is the Worst of Winter Over for COVID?

    Is the Worst of Winter Over for COVID?

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    For months, the winter forecast in the United States seemed to be nothing but viral storm clouds. A gale of RSV swept in at the start of autumn, sickening infants and children in droves and flooding ICUs. After a multiyear hiatus, flu, too, returned in force, before many Americans received their annual shot. And a new set of fast-spreading SARS-CoV-2 subvariants had begun its creep around the world. Experts braced for impact: “My biggest concern was hospital capacity,” says Katelyn Jetelina, who writes the popular public-health-focused Substack Your Local Epidemiologist. “If flu, RSV, and COVID were all surging at the same time—given how burned out, how understaffed our hospital systems are right now—how would that pan out?”

    But the season’s worst-case scenario—what some called a “tripledemic,” bad enough to make health-care systems crumble—has not yet come to pass. Unlike last year, and the year before, a hurricane of COVID hospitalizations and deaths did not slam the country during the first month of winter; flu and RSV now appear to be in sustained retreat. Even pediatric hospitals, fresh off what many described as their most harrowing respiratory season in memory, finally have some respite, says Mary Beth Miotto, a pediatrician and the president of the Massachusetts chapter of the American Academy of Pediatrics. After a horrific stint, “we are, right now, doing okay.” With two months to go until spring, there is plenty of time for another crisis to emerge: Certain types of influenza, in particular, can be prone to delivering late-season second peaks. “We need to be careful and recognize we’re still in the middle,” Jetelina told me. But so far, this winter “has not been as bad as I expected it to be.”

    No matter what’s ahead, this respiratory season certainly won’t go down in history as a good one. Children across the country have fallen sick in overwhelming numbers, many of them with multiple respiratory viruses at once, amid a nationwide shortage of pediatric meds. SARS-CoV-2 remains a top cause of mortality, with its daily death count still in the hundreds, and long COVID continues to be difficult to prevent or treat. And enthusiasm for new vaccines and virus-blocking mitigations seems to be at an all-time low. Any sense of relief people might be feeling at this juncture must be tempered by what’s in the rearview: three years of an ongoing pandemic that has left more than 1 million people dead in the U.S. alone, and countless others sick, many chronically so. The winter may be going better than it could have. But that shouldn’t hold us back from tackling what’s ahead this season, and in others yet to come.

    Not all of this past autumn’s gloomy predictions were off base. RSV and flu each rushed in on the early side of the season and led to a steep rise in cases. But both viruses made rather hasty exits: RSV hit an apparent apex in mid-November, and flu bent into its own decline the following month. The staggered peaks “helped us quite a bit, in terms of hospitals being stressed,” says Sam Scarpino, the director of AI and life sciences at the Institute for Experiential AI at Northeastern University. In recent days, coronavirus cases and hospitalizations have been tilting downward, too—and severe-disease rates seem to be holding at a relative low. Just under 5 percent of hospital beds are currently occupied by COVID patients, compared with more than four times that fraction this time last year. And weekly COVID deaths are down by almost 75 percent from January 2022. (Death, though, has always been a lagging indicator, and the mortality numbers could still shift upward soon.) Despite some dire predictions to the contrary, the fast-spreading XBB.1.5 subvariant didn’t spark “some giant Omicron-type wave and crush everything,” says Justin Lessler, an infectious-disease modeler at the University of North Carolina at Chapel Hill. “In that sense, I feel good.”

    Read: How worried should we be about XBB.1.5?

    No one can say for sure why we dodged winter’s deadliest bullets, but the population-level immunity that Americans have built up over the past three years clearly played a major role. “That’s a testament to how vaccination has made the disease less dangerous for most people,” says Cedric Dark, an emergency physician at Baylor College of Medicine. Widespread immunization, combined with the fact that most Americans have now been infected, and many of them reinfected, has caused severe-disease rates to plunge, and the virus to move less quickly than it otherwise would have. Antiviral drugs, too, have been slashing hospitalization rates, at least for the meager fraction of recently infected people who use them. The gargantuan asterisk of long COVID still applies to new infections, but the short-term effects of the disease are now more on par with those of other respiratory illnesses, reducing the number of resources that health-care workers must marshal for each case.

    The virus, too, was more merciful than it could have been. XBB.1.5, despite its high transmissibility and penchant for dodging antibodies, doesn’t so far seem more capable of causing severe disease. And the fall’s bivalent shots, though not a perfect match for the newcomer, still improve the body’s response to viruses in the Omicron clan. Competition among respiratory viruses may have also helped soften COVID’s recent blows. In the days and weeks after one infection, bodies can become more resilient to another—a phenomenon known as viral interference that can reduce the risk of simultaneous or back-to-back infections. On population scales, interference can push down surges’ peaks, or at the very least, separate them, potentially keeping hospitals from being hit by a medley of microbes all at once. It’s hard to say for sure: “Many things go into when an epidemic wave happens—human behavior, temperature, humidity, the biology of the virus, the biology of the host,” says Ellen Foxman, an immunologist at Yale. That said, “I do think viral interference probably does play a role that has not been appreciated.”

    None of the experts I spoke with was ready to issue a blanket phew. Overlapping waves of respiratory illness have already led to nonstop sickness, especially among children, draining resources at every point in the pediatric caregiving chain. Kids were kept out of school, and parents stayed home from work; after a glut of COVID-related closures in New Mexico, schools and day cares running low on teachers had to call in the National Guard. Inundated with illnesses, pediatric emergency rooms overflowed; adult-care units had to be repurposed for children, and some hospitals pitched tents on their front lawns to accommodate overflow. Local stopgaps weren’t always enough: At one point, a colleague of Miotto’s in Boston told her that the closest available pediatric ICU bed was in Washington, D.C.

    Read: The worst pediatric-care crisis in decades

    By any metric, for the pediatric community, “it’s been a horrible season, the worst,” says Yvonne Maldonado, a pediatrician at Stanford. “The hospitals were bursting, bursting at the seams.” The flow of fevers has ebbed somewhat in recent weeks, but remains more flood than trickle. “It’s not over: We still don’t have amoxicillin in general, and we still struggle to get fever medication for people,” Miotto said. A parent recently told her that they’d gone to almost 10 pharmacies to try to fill an antibiotic prescription for their child. And pediatric providers across the country are steeling themselves for what the coming weeks could bring. “I think we could still see another surge,” says Joelle Simpson, the division chief of emergency medicine at Children’s National Hospital. “In prior years, February has been one of the worst months.”

    The season’s ongoing woes have been compounded by preexisting health-care shortages. Amid a dearth of funds, some hospitals have reduced their number of pediatric beds; a mass exodus of workers has also limited the resources that can be doled out, even as SARS-CoV-2 testing and isolation protocols continue to stretch the admission and discharge timeline. “Hospitals are in a weaker position than they were before the pandemic,” says Joseph Kanter, Louisiana’s state health officer and medical director. “If that’s the environment in which we are experiencing this year’s respiratory-virus season, it makes everything feel more acute.” Those issues are not limited to pediatrics: Now that COVID is a regular part of the disease roster, workloads have increased for a contingent of beleaguered clinicians that, across the board, seems likely to continue to shrink. In many hospitals, patients are getting stuck in emergency departments for several hours, even multiple days—sometimes never making it to a bed before being sent home. “It seems like hospitals everywhere are full,” Dark told me, not just because of COVID, but because of everything. “The vast majority of the work I do, and that I bet you what most of my colleagues are doing, is taking place in waiting rooms.”

    The U.S. has come a long way in the past three years. But still, “the cumulative toll of these winter surges has been higher than it needs to be,” says Julia Raifman, a health-policy researcher at Boston University. Had more people gone into winter up to date on their COVID vaccines, the virus’s mortality rate could have been driven down further; had more antiviral drugs and other protections been prioritized for the elderly and immunocompromised, fewer people might have been imperiled at all. If relief is percolating across the country right now, that says more about a shift in standards than anything else. “Our threshold for what ‘bad’ looks like has just gotten so out of whack,” Simpson told me. This winter could have been as grim as recent ones, Scarpino told me, with body-filled freezer trucks in parking lots and hospitals on the brink of collapse. But an improvement from those horrific lows isn’t much to brag about. And this winter—three years into combatting a coronavirus for which we have shots, drugs, masks, and more—has been nowhere close to the best one imaginable.

    The concern now, experts told me, is that the U.S. might accept a winter like this one as simply good enough. Regular vaccine uptake could dwindle even further; another wild-card SARS-CoV-2 variant could ignite another conflagration of cases. If that did happen, some researchers worry that we’d be slow to notice: Genomic surveillance is down, and many tests are being taken, unreported, at home. And with so many different immune histories now scattered across the globe, it’s getting tougher for modelers like Lessler to predict where and how quickly new variants might take over.

    The country does have a few factors working in its favor. By next winter, at least one RSV vaccine will almost certainly be available to protect the population’s youngest, eldest, or both. mRNA-based flu vaccines, which are expected to be far faster to develop than currently available shots, are also in the works, and will likely make it easier to match doses to circulating strains. And if, as Foxman hopes, SARS-CoV-2 eventually settles into a more predictable, seasonal pattern, infections will be less of a concern for most of the year and season-specific immunizations could be easier to design.

    Read: Should everyone be masking again?

    But no vaccine will do much unless enough people are willing and able to take it—and the public-health infrastructure that’s led many outreach efforts remains underfunded and understaffed. Kanter worries that the nation may not be terribly willing to invest. “We’ve fallen into this complacency trap where we just accept a given amount of mortality every year as unavoidable,” he told me. It doesn’t have to be that way, as the past few years have shown: Treatments, vaccines, clean indoor air, and other measures can lower a respiratory virus’s toll.

    By the middle of spring, the U.S. will be in a position to let the public-health-emergency declaration on COVID lapse—a decision that could roll back protections for the uninsured, and ratchet up price points on shots and antivirals. This winter’s retrospective is likely to influence that decision, Scarpino told me. But relief can breed complacency, and complacency further slows a sluggish public-health response. The fate of next winter—and of every winter after that—will depend on whether the U.S. decides to view this season as a success, or to recognize it as a shaky template for well-being that can and should be improved.

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    Katherine J. Wu

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  • Trying to Stop Long COVID Before It Even Starts

    Trying to Stop Long COVID Before It Even Starts

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    Three years into the global fight against SARS-CoV-2, the arsenal to combat long COVID remains depressingly bare. Being vaccinated seems to reduce people’s chances of developing the condition, but the only surefire option for avoiding long COVID is to avoid catching the coronavirus at all—a proposition that feels ever more improbable. For anyone who is newly infected, “we don’t have any interventions that are known to work,” says Akiko Iwasaki, an immunologist and long-COVID researcher at Yale.

    Some researchers are hopeful that the forecast might shift soon. A pair of recent preprint studies, both now under review for publication in scientific journals, hint that two long-COVID-preventing pills might already be on our pharmacy shelves: the antiviral Paxlovid and metformin, an affordable drug commonly used for treating type 2 diabetes. When taken early in infection, each seems to at least modestly trim the chance of developing long COVID—by 42 percent, in the case of metformin. Neither set of results is a slam dunk. The Paxlovid findings did not come out of a clinical trial, and were focused on patients at high risk of developing severe, acute COVID; the metformin data did come out of a clinical trial, but the study was small. When I called more than half a dozen infectious-disease experts to discuss them, all used hopeful, but guarded, language: The results are “promising,” “intriguing”; they “warrant further investigation.”

    At this point, though, any advance at all feels momentous. Long COVID remains the pandemic’s biggest unknown: Researchers still can’t even agree on its prevalence or the features that define it. What is clear is that millions of people in the United States alone, and countless more worldwide, have experienced some form of it, and more are expected to join them. “We’ve already seen early data, and we’ll continue to see data, that that will emphasize the impact that long COVID has on our society, on quality of life, on productivity, on our health system and medical expenditures,” says Susanna Naggie, an infectious-disease physician and COVID-drug researcher at Duke University. “This needs to be a high priority,” she told me. Researchers have to trim long COVID incidence as much as possible, as soon as possible, with whatever safe, effective options they can.

    By now, news of the inertia around preventive long-COVID therapies may not come as much of a shock. Interventions that stop disease from developing are, on the whole, a neglected group; big, blinded, placebo-controlled clinical trials—the industry gold standard—usually look to investigate potential treatments, rather than drugs that might keep future illness at bay. It’s a bias that makes research easier and faster; it’s a core part of the American medical culture’s reactive approach to health.

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

    For long COVID, the terrain is even rougher. Researchers are best able to address prevention when they understand a disease’s triggers, the source of its symptoms, and who’s most at risk. That intel provides a road map, pointing them toward specific bodily systems and interventions. The potential causes of COVID, though, remain murky, says Adrian Hernandez, a cardiologist and clinical researcher at Duke. Years of research have shown that the condition is quite likely to comprise a cluster of diverse syndromes with different triggers and prognoses, more like a category (e.g., “cancer”) than a singular disease. If that’s the case, then a single preventive treatment shouldn’t be expected to cut its rates for everyone. Without a universal way to define and diagnose the condition, researchers can’t easily design trials, either. Endpoints such as hospitalization and death tend to be binary and countable. Long COVID operates in shades of gray.

    Still, some scientists might be making headway with vetted antiviral drugs, already known to slash the risk of developing severe COVID-19. A subset of long-COVID cases could be caused by bits of virus that linger in the body, prompting the immune system to wage an extended war; a drug that clears the microbe more quickly might lower the chances that any part of the invader sticks around. Paxlovid, which interferes with SARS-CoV-2’s ability to copy itself inside of our cells, fits that bill. “The idea here is really nipping it in the bud,” says Ziyad Al-Aly, a clinical epidemiologist and long-COVID researcher at Washington University in St. Louis, who led the recent Paxlovid work.

    Paxlovid has yet to hit the scientific jackpot: proof from a big clinical trial that shows it can prevent long COVID in newly infected people. But Al-Aly’s study, which pored over the electronic medical records of more than 56,000 high-risk patients, offers some early optimism. People who took the pills, he and his colleagues found, were 26 percent less likely to report lingering symptoms three months after their symptoms began than those who didn’t.

    Read: Inside the mind of an anti-Paxxer

    The pills’ main benefit remains the prevention of severe, acute disease. (In the recent study, Paxlovid-takers were also 30 percent less likely to be hospitalized and 48 percent less likely to die.) Al-Aly expects that the drug’s effectiveness at preventing long COVID—if it’s confirmed in other populations—will be “modest, not huge.” Though the two functions could yet be linked: Some long-COVID cases may result from severe infections that damage tissues so badly that the body struggles to recover. And should Paxlovid’s potential pan out, it could help build the case for testing other SARS-CoV-2 antivirals. Al-Aly and his colleagues are currently working on a similar study into molnupiravir. “The early results are encouraging,” he told me, though “not as robust as Paxlovid.” (Another study, run by other researchers, that followed hospitalized COVID patients found those who took remdesivir were less likely to get long COVID, but a later randomized clinical trial didn’t bear that out.)

    A clinical trial testing Paxlovid’s preventive potency against long COVID is still needed. Kit Longley, a spokesperson for Pfizer, told me in an email that the company doesn’t currently have one planned, though it is “continuing to monitor data from our clinical studies and real-world evidence.” (The company is collaborating with a research group at Stanford to study Paxlovid in new clinical contexts, but they’re looking at whether the pills  might treat long COVID that’s already developed. The RECOVER trial, a large NIH-funded study on long COVID, is also focusing its current studies on treatment.) But given the meager uptake rates for Paxlovid even among those in high-risk groups, Al-Aly thinks his new data could already serve a useful purpose: providing people with extra motivation to take the drug.

    The case for adding metformin to the anti-COVID tool kit might be a bit muddier. The drug isn’t the most intuitive medication to deploy against a respiratory virus, and despite its widespread use among diabetics, its exact effects on the body remain nebulous, says Stacey Schultz-Cherry, a virologist at St. Jude Children’s Research Hospital. But there are many reasons to believe it might be useful. Some research has shown that metformin can mess with the manufacture of viral proteins inside of human cells, Bramante told me, which may impede the ability of SARS-CoV-2 and other pathogens to reproduce. The drug also appears to rev up the disease-dueling powers of certain immune cells, and to stave off inflammation. Studies have shown that metformin can improve responses to certain vaccinations in humans and rodents, and researchers have found that people taking the drug seem less likely to get seriously sick from influenza. Even the diabetes-coronavirus connection may not be so tenuous: Metabolic disease is a risk factor for severe COVID; infection itself can put blood-sugar levels on the fritz. It’s certainly plausible that having a metabolically altered body, Schultz-Cherry told me, could make infections worse.

    Read: The promising treatment we’re not even trying for long COVID

    But the evidence that metformin helps prevent long COVID remains sparse. Carolyn Bramante, the scientist who led the metformin study, told me that when her team first set out in 2020 to investigate the drug’s effects on SARS-CoV-2 infections in a randomized, clinical trial, long COVID wasn’t really on their radar. Like many others in their field, they were hoping to repurpose established medicines to keep infected people out of the hospital; early studies of metformin—as well as the two other drugs in their trial, the antidepressant fluvoxamine and the antiparasitic ivermectin—hinted that they’d work. Ironically, two years later, their story flipped around. A large analysis, published last summer, showed that none of the three drugs were stellar at preventing severe COVID in the short term—a disappointing result (though Bramante contends that their data still indicate that metformin does some good). Then, when Bramante and her colleagues examined their data again, they found that study participants that had taken metformin for two weeks around the start of their illness were 42 percent less likely to have a long-COVID diagnosis from their doctor nearly a year down the road. David Boulware, an infectious-disease physician who helped lead the work, considers that degree of reduction pretty decent: “Is it 100 percent? No,” he told me. “But it’s better than zero.”

    Metformin may well prove to prevent long COVID but not acute, severe COVID (or vice versa). Plenty of people who never spend time in the hospital can still end up developing chronic symptoms. And Iwasaki points out that the demographics of long-haulers and people who get severe COVID don’t really overlap; the latter skew older and male. In the future, early-infection regimens may be multipronged: antivirals, partnered with metabolic drugs, in the hopes of keeping symptoms both mild and short-lived.

    But researchers are still a long way off from delivering that reality. It’s not yet clear, for instance, whether the drugs work additively when combined, Boulware told me. Nor is it a given that they’ll work across different demographics—age, vaccination status, risk factors, and more. Bramante and Boulware’s study cast a decently wide net: Although everyone enrolled in the trial was overweight or obese, many were young and healthy; a few were even pregnant. The study was not enormous, though—about 1,000 people. It also relied on patients’ individual doctors to deliver long-COVID diagnoses, likely leading to some inconsistencies, so other studies that follow up in the future could find different results. For now, this isn’t enough to “mean we should run out and use metformin,” Schultz-Cherry, who has been battling long COVID herself, told me.

    Other medications could still fill the long-COVID gaps. Hernandez, the Duke cardiologist, is hopeful that one of his ongoing clinical trials, ACTIV-6, might provide answers soon. He and his team are testing whether any of several drugs—including ivermectin, fluvoxamine, the steroid fluticasone, and, as a new addition, the anti-inflammatory montelukast—might cut down on severe, short-term COVID. But Hernandez and his colleagues, Naggie among them, appended a check-in at the 90-day mark, when they’ll be asking their patients whether they’re experiencing a dozen or so symptoms that could hint at a chronic syndrome.

    That check-in questionnaire won’t capture the full list of long-COVID symptoms, now more than 200 strong. Still, the three-month benchmark could give them a sense of where to keep looking, and for how long. Hernandez, Naggie, and their colleagues are considering whether to extend their follow-up period to six months, maybe farther. The need for long-COVID prevention, after all, will only grow as the total infection count does. “We’re not going to get rid of long COVID anytime soon,” Iwasaki told me. “The more we can prevent onset, the better off we are.”

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    Katherine J. Wu

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  • Can ‘Radical Rest’ Help With Long COVID Symptoms?

    Can ‘Radical Rest’ Help With Long COVID Symptoms?

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    Jan. 18, 2023 – On March 18, 2020, Megan Fitzgerald was lying on the floor of her Philadelphia home after COVID-19 hit her like a ton of bricks. She had a fever, severe digestive issues, and she couldn’t stand on her own. Yet there she was, splayed out in the bathroom, trying both to respond to work emails and entertain her 3-year-old son, who was attempting to entice her by passing his toys through the door. 

    She and her husband, both medical researchers, were working from home early in the pandemic with no child care for their toddler. Her husband had a grant application due, so it was all-hands-on-deck for the couple, even when she got sick. 

    “My husband would help me up and down stairs because I couldn’t stand,” Fitzgerald says.

    So, she put a mask on and tried to take care of her son, telling him, “Mommy’s sleeping on the floor again.” She regrets pushing so hard, having since discovered there may have been consequences. She often wonders: If she’d rested more during that time, would she have prevented the years of decline and disability that followed? 

    There’s growing evidence that overexertion and not getting enough rest in that acute phase of COVID-19 infection can make longer-term symptoms worse. 

    “The concept that I would be too sick to work was very alien to me,” Fitzgerald says. “It didn’t occur to me that an illness and acute virus could be long-term debilitating.” 

    Her story is common among long COVID-19 patients, not just for those who get severely ill but also those who only have moderate symptoms. It’s why many medical experts and researchers who specialize in long COVID rehabilitation recommend what’s known as radical rest – a term popularized by journalist and long COVID advocate Fiona Lowenstein – right after infection as well as a way of coping with the debilitating fatigue and crashes of energy that many have in the weeks, months, and years after getting sick.

    These sustained periods of rest and “pacing” – a strategy for moderating and balancing activity– have long been promoted by people with post-viral illnesses such as myalgic encephalomyelitis, or chronic fatigue syndrome (ME/CFS), which share many symptoms with long COVID.

    That’s why researchers and health care providers who have spent years trying to help patients with ME/CFS and, more recently, long COVID, recommend they rest as much as possible for at least 2 weeks after viral infection to help their immune systems. They also advise spreading out activities to avoid post-exertional malaise (PEM), a phenomenon where even minor physical or mental effort can trigger a flare-up of symptoms, including severe fatigue, headaches, and brain fog.

    An international study, done with the help of the U.S. Patient-Led Research Collaborative and published in The Lancet in 2021, found that out of nearly 1,800 long COVID patients who tried pacing, more than 40% said it helped them manage symptoms.

    Burden on Women and Mothers

    In another survey published last year, British researchers asked 2,550 long COVID patients about their symptoms and found that not getting enough rest in the first 2 weeks of illness, along with other things like lower income, younger age, and being female, were associated with more severe long COVID symptoms.

    It’s also not lost on many investigators and patients that COVID’s prolonged symptoms disproportionately affect women – many of whom don’t have disability benefits or a choice about whether they can afford to rest after getting sick. 

    “I don’t think it’s a coincidence, particularly in America, that women of reproductive age have been hit the hardest with long COVID,” says Fitzgerald. “We work outside the home, and we do a tremendous amount of unpaid labor in the home as well.”

    How Does Lack of Rest Affect People With COVID?

    Experts are still trying to understand the many symptoms and mechanisms behind long COVID. But until the science is settled, both rest and pacing are two of the most solid pieces of advice they can offer, says David Putrino, PhD, a neuroscientist and physical therapist who has worked with thousands of long COVID patients at Mount Sinai Hospital in New York. “These things are currently the best defense we have against uncontrolled disease progression,” he says.

    There are many recommended guides for rest and pacing for those living with long COVID, but ultimately, patients need to carefully develop their own personal strategies that work for them, says Putrino. He calls for research to better understand what’s going wrong with each patient and why they may respond differently to similar strategies. 

    There are several theories on how long COVID infection triggers fatigue. One is that inflammatory molecules called cytokines, which are higher in long COVID patients, may injure the mitochondria that fuel the body’s cells, making them less able to use oxygen. 

    “When a virus infects your body, it starts to hijack your mitochondria and steal energy from your own cells,” says Putrino. Attempts to exercise through that can significantly increase the energy demands on the body, which damages the mitochondria, and also creates waste products from burning that fuel, kind of like exhaust fumes, he explains. It drives oxidative stress, which can damage the body.

    “The more we look objectively, the more we see physiological changes that are associated with long COVID,” he says. “There is a clear organic pathobiology that is causing the fatigue and post-exertional malaise.”

    To better understand what’s going on with infection associated with complex chronic illnesses such as long COVID and ME/CFS, Putrino’s lab is looking at things like mitochondrial dysfunction and blood biomarkers such as microclots. 

    He also points to research by pulmonologist David Systrom, MD, director of the Advanced Cardiopulmonary Exercise Testing Program at Brigham and Women’s Hospital and Harvard Medical School. Systrom has done invasive exercise testing experiments that show that people with long COVID have a different physiology than people who have had COVID and recovered. His studies suggest that the problem doesn’t lie with the functioning of the heart or lungs, but with blood vessels that aren’t getting enough blood and oxygen to the heart, brain, and muscles.

    Why these blood vessel problems occur is not yet known, but one study led by Systrom’s colleague, neurologist Peter Novak, MD, PhD, suggests that the small nerve fibers in people with long COVID are missing or damaged. As a result, the fibers fail to properly squeeze the big veins (in the legs and belly, for instance) that lead to the heart and brain, causing symptoms such as fatigue, PEM, and brain fog. Systrom has seen similar evidence of dysfunctional or missing nerves in people with other chronic illnesses such as ME/CFS, fibromyalgia, and postural orthostatic tachycardia syndrome (POTS).

    “It’s been incredibly rewarding to help patients understand what ails them and it’s not in their head and it’s not simple detraining or deconditioning,” says Systrom, referring to misguided advice from some doctors who tell patients to simply exercise their way out of persistent fatigue. 

    These findings are also helping to shape specialized rehab for long COVID at places like Mount Sinai and Brigham and Women’s hospitals, whose programs also include things like increasing fluids and electrolytes, wearing compression clothing, and making diet changes. And while different types of exercise therapies have long been shown to do serious damage to people with ME/CFS symptoms, both Putrino and Systrom say that skilled rehabilitation can still involve small amounts of exercise when cautiously prescribed and paired with rest to avoid pushing patients to the point of crashing. In some cases, the exercise can be paired with medication.

    In a small clinical trial published in November, Systrom and his research team found that patients with ME/CFS and long COVID were able to increase their exercise threshold with the help of a POTS drug, Mestinon, known generically as pyridostigmine, taken off label.

    As is the case of many people with long COVID, Fitzgerald’s recovery has had ups and downs. She now has more help with child care and a research job with the disability-friendly Patient-Led Research Collaborative. While she hasn’t gotten into a long COVID rehab group, she’s been teaching herself pacing and breathwork. In fact, the only therapeutic referral she got from her doctor was for cognitive behavioral therapy, which has been helpful for the toll the condition has taken emotionally. “But it doesn’t help any of the physical symptoms,” Fitzgerald says.

    She’s not the only one who finds that a problem.

    “We need to continue to call out people who are trying to psychologize the illness as opposed to understanding the physiology that is leading to these symptoms,” says Putrino. “We need to make sure that patients actually get care as opposed to gaslighting.”

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  • Add This to the List of Long COVID Symptoms: Stigma

    Add This to the List of Long COVID Symptoms: Stigma

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    Jan. 13, 2023 – People with long COVID may have dizziness, headaches, sleep problems, sluggish thinking, and many other problems. But they can also face another problem – stigma.

    Most people with long COVID find they’re facing stigma due to their condition, according to a new report from researchers in the United Kingdom. In short: Relatives and friends may not believe they’re truly sick.

    The U.K. team found that more than three-quarters of people studied had experienced stigma often or always. 

    In fact, 95% of people with long COVID faced at least one type of stigma at least sometimes, according to the study, published in November in the journal PLOS One. 

    Those conclusions had surprised the study’s lead researcher, Marija Pantelic, PhD, a public health lecturer at Brighton and Sussex Medical School.

    “After years of working on HIV-related stigma, I was shocked to see how many people were turning a blind eye to and dismissing the difficulties experienced by people with long COVID,” Pantelic says. “It has also been clear to me from the start that this stigma is detrimental not just for people’s dignity, but also public health.”

    Even some doctors argue that the growing attention paid to long COVID is excessive. 

    “It’s often normal to experience mild fatigue or weaknesses for weeks after being sick and inactive and not eating well. Calling these cases long COVID is the medicalization of modern life,” Marty Makary, MD, a surgeon and public policy researcher at the Johns Hopkins School of Medicine, wrote in a commentary in The Wall Street Journal. 

    Other doctors strongly disagree, including Alba Azola, MD, co-director of the Johns Hopkins Post-Acute COVID-19 Team and an expert in the stigma surrounding long COVID. 

    “Putting that spin on things, it’s just hurting people,” she says. 

    One example is people who cannot return to work.

    “A lot of their family members tell me that they’re being lazy,” Azola says. “That’s part of the public stigma, that these are people just trying to get out of work.” 

    Some experts say the U.K. study represents a landmark. 

    “When you have data like this on long COVID stigma, it becomes more difficult to deny its existence or address it,” says Naomi Torres-Mackie, PhD, a clinical psychologist at Lenox Hill Hospital in New York City. She also is head of research at the New York-based Mental Health Coalition, a group of experts working to end the stigma surrounding mental health.

    She recalls her first patient with long COVID.

    “She experienced the discomfort and pain itself, and then she had this crushing feeling that it wasn’t valid, or real. She felt very alone in it,” Torres-Mackie says. 

    Another one of her patients is working at her job from home but facing doubt about her condition from her employers.

    “Every month, her medical doctor has to produce a letter confirming her medical condition,” Torres-Mackie says.

    Taking part in the British stigma survey were 1,166 people, including 966 residents of the United Kingdom, with the average age of 48. Nearly 85% were female, and more than three-quarters were educated at the university level or higher.

    Half of them said they had a clinical diagnosis of long COVID.

    More than 60% of them said that at least some of the time, they were cautious about who they talked to about their condition. And fully 34% of those who did disclose their diagnosis said that they regretted having done so.

    That’s a difficult experience for those with long COVID, says Leonard Jason, PhD, a professor of psychology at DePaul University in Chicago.

    “It’s like they’re traumatized by the initial experience of being sick, and retraumatized by the response of others to them,” he says.

    Unexplained illnesses are not well-regarded by the general public, Jason says. 

    He gave the example of multiple sclerosis. Before the 1980s, those with MS were considered to have a psychological illness, he says. “Then, in the 1980s, there were biomarkers that said, ‘Here’s the evidence.’”

    The British study described three types of stigma stemming from the long COVID diagnosis of those questioned:

    • Enacted stigma: People were directly treated unfairly because of their condition.
    • Internalized stigma: People felt embarrassed by that condition.
    • Anticipated stigma: People expected they would be treated poorly because of their diagnosis.

    Azola calls the medical community a major problem when it comes to dealing with long COVID.

    “What I see with my patients is medical trauma,” she says. They may have symptoms that send them to the emergency room, and then the tests come back negative. “Instead of tracking the patients’ symptoms, patients get told, ‘Everything looks good, you can go home, this is a panic attack,’” she says.

    Some people go online to search for treatments, sometimes launching GoFundMe campaigns to raise money for unreliable treatments. 

    Long COVID patients may have gone through five to 10 doctors before they arrive for treatment with the Hopkins Post-Acute COVID-19 Team. The clinic began in April 2020 remotely and in August of that year in person.

    Today, the clinic staff spends an hour with a first-time long COVID patient, hearing their stories and helping relieve anxiety, Azola says. 

    The phenomenon of long COVID is similar to what patients have had with chronic fatigue syndrome, lupus, or fibromyalgia, where people have symptoms that are hard to explain, says Jennifer Chevinsky, MD, deputy public health officer for Riverside County, CA.

    “Stigma within medicine or health care is nothing new,” she says.

    In Chicago, Jason notes that the federal government’s decision to invest hundreds of millions of dollars in long COVID research “shows the government is helping destigmatize it.”

    Pantelic says she and her colleagues are continuing their research. 

    “We are interested in understanding the impacts of this stigma, and how to mitigate any adverse outcomes for patients and services,” she says.

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  • How Worried Should We Be About XBB.1.5?

    How Worried Should We Be About XBB.1.5?

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    After months and months of SARS-CoV-2 subvariant soup, one ingredient has emerged in the United States with a flavor pungent enough to overwhelm the rest: XBB.1.5, an Omicron offshoot that now accounts for an estimated 75 percent of cases in the Northeast. A crafty dodger of antibodies that is able to grip extra tightly onto the surface of our cells, XBB.1.5 is now officially the country’s fastest-spreading coronavirus subvariant. In the last week of December alone, it zoomed from 20 percent of estimated infections nationwide to 40 percent; soon, it’s expected to be all that’s left, or at least very close. “That’s the big thing everybody looks for—how quickly it takes over from existing variants,” says Shaun Truelove, an infectious-disease modeler at Johns Hopkins University. “And that’s a really quick rise.”

    All of this raises familiar worries: more illness, more long COVID, more hospitalizations, more health-care system strain. With holiday cheer and chilly temperatures crowding people indoors, and the uptake of bivalent vaccines at an abysmal low, a winter wave was already brewing in the U.S. The impending dominance of an especially speedy, immune-evasive variant, Truelove told me, could ratchet up that swell.

    But the American public has heard that warning many, many, many times before—and by and large, the situation has not changed. The world has come a long way since early 2020, when it lacked vaccines and drugs to combat the coronavirus; now, with immunity from shots and past infections slathered across the planet—porous and uneven though that layer may be—the population is no longer nearly so vulnerable to COVID’s worst effects. Nor is XBB.1.5 a doomsday-caliber threat. So far, no evidence suggests that the subvariant is inherently more severe than its predecessors. When its close sibling, XBB, swamped Singapore a few months ago, pushing case counts up, hospitalizations didn’t undergo a disproportionately massive spike (though XBB.1.5 is more transmissible, and the U.S. is less well vaccinated). Compared with the original Omicron surge that pummeled the nation this time last year, “I think there’s less to be worried about,” especially for people who are up to date on their vaccines, says Mehul Suthar, a viral immunologist at Emory University who’s been studying how the immune system reacts to new variants. “My previous exposures are probably going to help against any XBB infection I have.”

    SARS-CoV-2’s evolution is still worth tracking closely through genomic surveillance—which is only getting harder as testing efforts continue to be pared back. But “variants mean something a little different now for most of the world than they did earlier in the pandemic,” says Emma Hodcroft, a molecular epidemiologist at the University of Bern, in Switzerland, who’s been tracking the proportions of SARS-Cov-2 variants around the world. Versions of the virus that can elude a subset of our immune defenses are, after all, going to keep on coming, for as long as SARS-CoV-2 is with us—likely forever, as my colleague Sarah Zhang has written. It’s the classic host-pathogen arms race: Viruses infect us; our bodies, hoping to avoid a similarly severe reinfection, build up defenses, goading the invader into modifying its features so it can infiltrate us anew.

    Read: How long can the coronavirus keep infecting us?

    But the virus is not evolving toward the point where it’s unstoppable; it’s only switching up its fencing stance to sidestep our latest parries as we do the same for it. A version of the virus that succeeds in one place may flop in another, depending on the context: local vaccination and infection histories, for instance, or how many elderly and immunocompromised individuals are around, and the degree to which everyone avoids trading public air. With the world’s immune landscape now so uneven, “it’s getting harder for the virus to do that synchronized wave that Omicron did this time last year,” says Verity Hill, an evolutionary virologist at Yale. It will keep trying to creep around our defenses, says Pavitra Roychoudhury, who’s monitoring SARS-CoV-2 variants at the University of Washington, but “I don’t think we need to have alarm-bell emojis for every variant that comes out.”

    Read: The coronavirus’s next move

    Some particularly worrying variants and subvariants will continue to arise, with telltale signs, Roychoudhury told me: a steep increase in wastewater surveillance, followed by a catastrophic climb in hospitalizations; a superfast takeover that kicks other coronavirus strains off the stage in a matter of days or weeks. Omens such as these hint at a variant that’s probably so good at circumventing existing immune defenses that it will easily sicken just about everyone again—and cause enough illness overall that a large number of cases turn severe. Also possible is a future variant that is inherently more virulent, adding risk to every new case. In extreme versions of these scenarios, tests, treatments, and masks might need to come back into mass use; researchers may need to concoct a new vaccine recipe  at an accelerated pace. But that’s a threshold that most variations of SARS-CoV-2 will not clear—including, it seems so far, XBB.1.5. Right now, Hodcroft told me, “it’s hard to imagine that anything we’ve been seeing in the last few months would really cause a rush to do a vaccine update,” or anything else similarly extreme. “We don’t make a new flu vaccine every time we see a new variant, and we see those all through the year.” Our current crop of BA.5-focused shots is not a great match for XBB.1.5, as Suthar and his colleagues have found, at least on the antibody front. But antibodies aren’t the only defenses at play—and Suthar told me it’s still far better to have the new vaccine than not.

    In the U.S., wastewater counts and hospitalizations are ticking upward, and XBB.1.5 is quickly elbowing out its peers. But the estimated infection rise doesn’t seem nearly as steep as the ascension of the original Omicron variant, BA.1 (though our tracking is now poorer). XBB.1.5 also isn’t dominating equally in different parts of the country—and Truelove points out that it doesn’t yet seem tightly linked to hospitalizations in the places where it’s gained traction so far. As tempting as it may be to blame any rise in cases and hospitalizations on the latest subvariant, our own behaviors are at least as important. Drop-offs in vaccine uptake or big jumps in mitigation-free mingling can drive spikes in illness on their own. “We were expecting a wave already, this time of year,” Hill told me. Travel is up, masking is down. And just 15 percent of Americans over the age of 5 have received a bivalent shot.

    The pace at which new SARS-CoV-2 variants and subvariants take over could eventually slow, but the experts I spoke with weren’t sure this would happen. Immunity across the globe remains patchy; only a subset of countries have access to updated bivalent vaccines, while some countries are still struggling to get first doses into millions of arms. And with nearly all COVID-dampening mitigations “pretty much gone” on a global scale, Hodcroft told me, it’s gotten awfully easy for the coronavirus to keep experimenting with new ways to stump our immune defenses. XBB.1.5 is both the product and the catalyst of unfettered spread—and should that continue, the virus will take advantage again.

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    Katherine J. Wu

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  • Is Long COVID Less Likely With Omicron Strains?

    Is Long COVID Less Likely With Omicron Strains?

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    SOURCES:

    Jonathan Whiteson, MD, co-director, NYU Langone Health Post COVID Care Program.

    American Academy of Physical Medicine and Rehabilitation: “Long COVID/PASC.”

    Lancet: “Risk of Long COVID Associated With Delta Versus Omicron Variants of SARS-CoV-2.”

    Nature Communications: “Post-Covid Medical Complaints Following Infection With SARS-CoV-2 Omicron vs Delta Variants.”

    Karin Magnusson, PhD, researcher, Norwegian Institute of Public Health, Oslo, and Lund University, Sweden.

    FDA: “COVID-19 Bivalent Vaccine Boosters.”

    medRxiv: “Long COVID Risk and Pre-COVID Vaccination: An EHR-Based Cohort Study From the RECOVER Program.”

    Antimicrobial Stewardship & Healthcare Epidemiology: “The Effectiveness of Coronavirus Disease 2019 (COVID-19) Vaccine in the Prevention of Post-COVID Conditions: A Systematic Literature Review and Meta-Analysis.”

    Alexandre Marra, MD, researcher, Hospital Israelita Albert Einstein, São Paulo, Brazil; researcher, University of Iowa Carver College of Medicine, Iowa City.

    FDA: “Coronavirus (COVID-19) Update: FDA Authorizes Moderna, Pfizer-BioNTech Bivalent COVID-19 Vaccines for Use as a Booster Dose.”

    FDA: “Coronavirus (COVID-19) Update: FDA Authorizes Updated (Bivalent) COVID-19 Vaccines for Children Down to 6 Months of Age.”

    Daniel Brannock, research data scientist, RTI International.

    CDC: “Respiratory Infections.”

    European Center for Disease Prevention and Control: “Prevalence of Post COVID-19 Condition Symptoms: A Systematic Review and Meta-Analysis of Cohort Study Data, Stratified by Recruitment Setting.”

    Journal of Internal Medicine: “Post COVID-19 Condition Diagnosis: A Population-Based Cohort Study of Occurrence, Associated Factors, and Healthcare Use by Severity of Acute Infection.”

    Akiko Iwasaki, PhD, director, Center for Infection and Immunity, Yale University.

    American Academy of Physical Medicine and Rehabilitation: “PASC Dashboard.”

    National Center for Health Statistics: “Identification of Deaths With Post-acute Sequelae of COVID-19 From Death Certificate Literal Text: United States, January 1, 2020–June 30, 2022.”

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  • COVID Isolated People. Long COVID Makes It Worse

    COVID Isolated People. Long COVID Makes It Worse

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    Dec. 21, 2022 — A year ago in December, mapping specialist Whitney Tyshynski, 35, was working out 5 days a week with a personal trainer near her home in Alberta, Canada, doing 5k trail runs, lifting heavy weights, and feeling good. Then, in January she got COVID-19. The symptoms never went away.

    Nowadays, Tyshynski needs a walker to retrieve her mail, a half-block trip she can’t make without fear of fainting. Because she gets dizzy when she drives, she rarely goes anywhere in her car. Going for a dog walk with a friend means sitting in a car and watching the friend and the dogs in an open field. And since fainting at Costco during the summer, she’s afraid to shop by herself. 

    Because she lives alone and her closest relatives are an hour and a half away, Tyshynski is dependent on friends. But she’s reluctant to lean on them because they already have trouble understanding how debilitating her lingering symptoms can be. 

    “I’ve had people pretty much insinuate that I’m lazy,” she says. 

    There’s no question that COVID-19 cut people off from one another. But for those like Tyshynski who have long COVID, that disconnect has never ended. It’s not just that symptoms including extreme fatigue and brain fog make it difficult to socialize; it’s that people who had COVID-19 and recovered are often skeptical that the condition is real.

    At worst, as Tyshynski has discovered, people don’t take it seriously and accuse those who have it of exaggerating their health woes. In that way, long COVID can be as isolating as the original illness.

    “Isolation in long COVID comes in various forms and it’s not primarily just that physical isolation,” says Yochai Re’em, MD, a psychiatrist in private practice in New York City who has experienced long COVID and blogs about the condition for Psychology Today. “A different yet equally challenging type of isolation is the emotional isolation, where you need more emotional support, connection with other people who can appreciate what it is you are going through without putting their own needs and desires onto you — and that can be hard to find.” 

    It’s hard to find in part because of what Re’em sees as a collective belief that anyone who feels bad should be able to get better by exercising, researching, or going to a doctor. 

    “Society thinks you need to take some kind of action and usually that’s a physical action,” he says. “And that attitude is tremendously problematic in this illness because of the post-exertional malaise that people experience: When people exert themselves, their symptoms get worse. And so the action that people take can’t be that traditional action that we’re used to taking in our society.”

    Long COVID patients often have their feelings invalidated not just by friends, loved ones, and extended family, but by health care providers. That can heighten feelings of isolation, particularly for people who live alone, says Jordan Anderson, DO, a neuropsychiatrist and assistant professor of psychiatry in the School of Medicine at Oregon Health & Science University in Portland. 

    The first patients Anderson saw as part of OHSU’s long COVID program contracted the virus in February 2020. Because the program addresses both the physical and mental health components of the condition, Anderson has seen a lot of people whose emotional challenges are similar to those Tyshynski faces. 

    “I think there’s a lack of understanding that leads to people just not necessarily taking it seriously,” he says. “Plus, the symptoms of long COVID do wax and wane. They’re not static. So people can be feeling pretty good one day and be feeling terrible the next. There’s some predictability to it, but it’s not absolutely predictable. It can be difficult for people to understand.”

    Both Anderson and Re’em stress that long COVID patients need to prioritize their own energy regardless of what they’re being told by those who don’t understand the illness. Anderson offers to speak to his patients’ spouses to educate them about the realities of the condition because, he says, “any kind of lack of awareness or understanding in a family member or close support could potentially isolate the person struggling with long COVID.”

    Depending on how open-minded and motivated a friend or relative is, they might develop more empathy with time and education, Re’em says. But for others, dealing with a confusing, unfamiliar chronic illness can be overwhelming and provoke anxiety. 

    “The hopelessness is too much for them to sit with, so instead they say things like ‘just push through it,’ or ‘just do X, Y, and Z’ because psychologically it’s too much for them to take on that burden,’ he says.

    The good news is that there are plenty of web-based support groups for people with long COVID, including Body Politic (which Re’em is affiliated with), Survivor Corps, and on Facebook. “The patient community with this illness is tremendous, absolutely tremendous,” Re’em says. “Those people can be found and they can support each other.”

    Some long COVID clinics run groups, as do individual practitioners such as Re’em, although those can be challenging to join. For instance, Re’em’s are only for New York state residents. 

    The key to finding a group is to be patient, because finding the right one takes time and energy. 

    “There are support groups that exist, but they are not as prevalent as I would like them to be,” Anderson says. 

    OHSU had an educational support group run by a social worker affiliated with the long COVID hub, but when the social worker left the program, the program was put on hold.

    There’s a psychotherapy group operating out of the psychiatry department, but the patients are recruited exclusively from Anderson’s clinic and access is limited. 

    “The services exist, but I think that generally they’re sparse and pretty geographically dependent,” Anderson says. “I think you’d probably more likely be able to find something like this in a city or an area that has an academic institution or a place with a lot of resources rather than out in a rural community.”

    Tyshynski opted not to join a group for fear it would increase the depression and anxiety that she had even before developing long COVID. When she and her family joined a cancer support group when her father was ill, she found it more depressing than helpful. Where she has found support is from the co-founder of the animal rescue society where she volunteers, a woman who has had long COVID for more than 2 years and has been a source of comfort and advice.

    It’s one of the rare reminders Tyshysnki has that even though she may live alone, she’s not completely alone. “Other people are going through this, too,” she says. “It helps to remember that.”

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  • Long COVID Risk Makes It Worth Avoiding Second Infections

    Long COVID Risk Makes It Worth Avoiding Second Infections

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    Dec. 19, 2022 — Alexander Truong, MD, has been seeing long COVID patients for more than 2 years but thought the numbers would have significantly dwindled by now. Instead, a steady flow of patients still shows up at the Emory Executive Park post-COVID clinic he and a colleague launched in fall 2020 in Atlanta. And among patients infected more than once, the symptoms appear worse.

    “We are definitely seeing a lot of patients who, when they get reinfected, have worsening post-COVID issues. That’s very true and I think that’s a big signal,” says Truong, a pulmonologist and an assistant professor at Emory University’s School of Medicine.

    COVID-19 is definitely not over, says Angela Cheung, MD, PhD, a senior physician scientist with the University Health Network and a professor of medicine at the University of Toronto. And each time someone gets infected, they risk developing long COVID. A prior infection does not erase the risk, Cheung says.

    “It’s not like, ‘Oh, I’ve had one, so it’s OK. Now I can take off my mask, do what I like.’ It has health consequences for reinfections – higher mortality rate, higher hospitalization rates, higher risk of long term, lingering symptoms,” she says.

    New research suggests that those infected more than once have an increased risk of developing long COVID and other health problems compared to those infected just once. But parsing out the extent of these risks – particularly with newer variants – is more complicated, Truong and other experts say, particularly when factoring in vaccinations and antiviral treatments. 

    “It makes sense that repeat infections would not be beneficial to a person’s health. But I think it’s really hard to know what the additional risk of each subsequent infection would be because there are all sorts of other things in the mix,” says Michael Peluso, MD, an assistant professor of medicine and an infectious diseases doctor at the University of California San Francisco.

    “There are vaccines — new vaccines, old vaccines. There are variants — old variants, new variants, and now multiple variants circulating at the same time.”

    Veterans Affairs Study

    A large study involving the records of 5.8 million Department of Veterans Affairs patients that was published in Nature Medicine in November found that patients infected more than once had significantly higher risks of death, hospitalization, heart problems, blood clotting, long COVID, and a host of other health issues and organ damage. Notably, the study found that these elevated risks remained even 6 months after reinfection.

    While the study highlights the increased risks associated with reinfections, it has its limitations. The study did not directly compare a first infection to reinfection within the same pool of patients. It only compared one group of individuals who had a single infection to a separate group who had more than one infection. 

    There could be other factors that made one group more susceptible to reinfection and at greater risk of adverse health outcomes. The study also did not compare reinfection risks between different variants or subvariants.

    Another limitation is the VA population itself. The VA database is extremely useful for large studies like this one because it follows a large number of people with comprehensive medical records, experts say, but the VA’s population of mostly older white males does not reflect the demographics of the general population.

    Nonetheless, the message for the public is straightforward, says Cheung. “I wouldn’t get into the weeds. The big message and big picture is that reinfections are bad.”

    Different Risks With New Variants?

    Experts say understanding reinfection risks, particularly with the newer variants and subvariants, is complicated because more people are now vaccinated compared to earlier in the pandemic.

    “There are not any definitive answers. … It’s very, very difficult to disentangle the emergence of new variants from the uptake of vaccines,” says Peluso.

    “It does seem like overall there may be less long COVID with the newer variants, but it’s very hard to say whether that is a characteristic of the virus or a characteristic of the fact that most people who are getting the virus have either been vaccinated or previously infected to have some different immune baseline from somebody who’s seeing the viral antigen for the first time.”

    However, consensus is growing that those who are vaccinated and end up with breakthrough infections are at lower risk of developing long COVID. One U.K. study published in the journal Open Forum Infectious Diseases in September, for example, found that people who had two COVID-19 vaccinations at least 2 weeks prior to infection had a 41% decrease in the odds of developing long COVID symptoms, compared to people who were not vaccinated at the time of infection.

    “We also know that in patients who’ve had their vaccinations, they are less likely to have a reinfection, or when they do have reinfection, they’re less likely to have severe infection,” says Truong.

    “That’s the one big signal that we have and that’s why I’m trying to wave the flag as much as I can about getting vaccinated [and boosted].”

    While some data suggests the risks of long COVID are lower with Omicron variants compared with the Delta variant, experts point out that a far greater number of people have been infected with Omicron, so even a small percentage of a large number is still a large number. 

    “One study looking at Omicron versus Delta shows about half the risk, but half the risk in a lot more people is still a lot of high absolute numbers,” Cheung says, referring to a June paper published in The Lancet. 

    She still sees a lot of patients with long COVID – some infected as recently as this past summer, some vaccinated and infected for the first time, and others coming in following reinfections.

    And while Omicron variant and subvariant infections may appear milder for many people, doctors note new patients are also showing up with the same debilitating symptoms as those who got long COVID earlier in the pandemic: fatigue, shortness of breath, racing heart, brain fog, sleep disturbances, and mental health issues.

    “On my post-COVID clinic days, I’m still seeing four to eight new patients who had infections in 2022 come in with significant symptoms,” says Truong.

    And long COVID can kill. More than 3,500 death certificates filed from the start of the pandemic through June 2022 list long COVID as a specific cause of death, the National Center for Health Statistics reports.

    Minimizing Post-COVID Risks

    Peluso says what can be learned from the VA study is that repeated attacks on the immune system are dangerous and that continuing to avoid infection remains extremely important.

    “The best way for someone to protect themselves against that is to avoid getting COVID in the first place,” says Peluso. It is a sentiment echoed by Truong and Cheung.

    But given the transmissibility of the newest variants and subvariants and the removal of public health measures, it’s often difficult to prevent infection. Tried and true tools do, however, work: being up to date on vaccinations, wearing high-quality, well-fitted masks, advocating for good ventilation, and conducting self-testing with rapid antigen tests, particularly ahead of indoor events during busy holiday periods.

    “It’s possible that this may become less common over time. I hope that’s true,” Peluso says. 

    “It’s also possible that it might go the other way. And so for that reason, I’m trying to avoid all of the variants.”

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  • Long COVID Linked to More than 3,500 Deaths: CDC Report

    Long COVID Linked to More than 3,500 Deaths: CDC Report

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    Dec. 15, 2022 – More than 3,500 Americans died from long COVID during the first years of the pandemic, a new CDC report reveals. Men, people over 75, and American Indian/Alaska Native populations were at the highest risk of dying. 

    The CDC study is “certainly very sobering,” says William Schaffner, MD, a professor of medicine in the Division of Infectious Diseases at Vanderbilt University School of Medicine in Nashville.

    The new information shows that long COVID is more serious than many people previously considered, he says. “We know that long COVID is very common, and it’s causing a lot of grief for a lot of patients. Fortunately, over time, many of these patients improve.”

    However, “now we see from the CDC report that, actually, some people are going to die,” says Schaffner, who is also medical director of the National Foundation for Infectious Diseases. 

    Researchers at the CDC’s Center for Health Statistics looked at death certificates that mentioned long COVID (or chronic COVID, long haul COVID, post COVID syndrome, and others) as a cause of death or a contributing factor. They matched these certificates to medical records with a code related to COVID-19. 

    They identified 3,544 Americans who died from long COVID from Jan. 1, 2020, through June 30, 2022. This group is a fraction of the 1.02 million people who died from COVID-19 during that time. Their findings are published in the December 2022 CDC Vital Statistics Rapid Release report.

    “I think the study’s fascinating and interesting. It brings perspective to the consequences of COVID even after we’ve finished focusing on the acute infection itself,” says Thomas Gut, DO, associate chair of medicine and medical director of the Post-COVID Recovery Center at Staten Island University Hospital in New York City.

    It’s still early days, he says. “This is just the tip of the iceberg … for the consequences that we’re going to be facing long term.”

    Regarding the 3,500 deaths, “I think it’s a low number overall,” Gut says. “There’s probably a lot more people that have died. We probably missed a lot of long COVID early on, not realizing that’s what it was.”

    It’s unlikely death certificates earlier in the pandemic would include the acute COVID infection as a cause of death 3 to 6 months later, for example, Gut says. Going forward, this could change. Long COVID is a chronic condition, so it’s more likely to be listed listed on a death certificate. 

    Some at Higher Risk

    More than half of the deaths linked to long COVID, 57%, occurred in people ages 75 and older. Also, men accounted for 51.5% of long COVID deaths.

    Furthermore, 79% of long COVID deaths were non-Hispanic white people, followed by 10% non-Hispanic Black people and about 8% Hispanic people. 

    Even though non-Hispanic American Indian/Alaska Native people experienced less than 2% of all the long COVID deaths in the study, they emerged as a high-risk group in a separate analysis. Their age-adjusted death rate for long COVID was highest, at 14.8 deaths per 1 million people. In contrast, non-Hispanic Asian people had the lowest age-adjusted death rate, at 1.5 per 1 million.

    Minority groups like American Indians and Alaska Natives “have been disproportionately affected by the virus from the beginning of the pandemic – and have been also among the harder to reach and to provide access to the vaccine,” Schaffner says.

    This report shows that efforts to reach these underserved communities continues to be essential, he says. “We need to keep doing that – and if we needed another reason to do that, here it is.”

    The CDC researchers propose a bleak reason why higher death rates from long COVID were not found among non-Hispanic Black and Hispanic people in the study, despite these groups having higher COVID-19 mortality rates: Many COVID-19 patients in these groups likely died of their original disease before they could develop long COVID. 

    Some Study Limitations

    Although the medical community continues to learn and acknowledge the burden of long COVID and health care professionals have been using the term more, there is lots of variability, since we still do not a have a unified diagnosis of this illness . 

    “The fact that the number of long COVID labeled deaths has been increasing over time could be a result of more awareness among the medical community, and therefore make it very challenging to draw specific conclusions from this study,” says Fidaa Shaib, MD, an associate professor of medicine in the section of pulmonary, critical care, and sleep medicine, and director of the Post COVID Care Clinic at Baylor College of Medicine in Houston. 

    Even though the study found more deaths among men, “our experience and the experience of others have shown that PASC [post-acute sequelae of COVID] or long COVID patients are predominantly middle-aged women.”

    Shaib points out some limitations of the study. Some causes of long COVID deaths could be from other disorders – like heart disease – that increase the risk of death from acute COVID-19 itself. Also, the data did not include information about the length of time from the original COVID-19 illness to the time of death. “Therefore, the PASC/long COVID diagnosis might not be very accurate.”

    “Overall, this study is a good start to draw more attention about the seriousness of acute and long COVID illnesses,” Shaib says, “but more specific data is needed.”

    Keeping ‘the Pedal on the Metal’

    Avoiding COVID-19 in the first place remains the best protection against long COVID, Schaffner says. Like many public health officials, he emphasized the importance of staying up to date on COVID vaccinations as the most effective strategy. 

    “As a population, the United States has really not taken sufficient advantage of the freely available – and really quite effective – boosters that are out there now.” The latest CDC estimates report that 13.5% of Americans 5 years and older have received an updated booster dose. 

    For this reason, “we need to really to keep the pedal on the metal, trying to get the message out,” Schaffner says.

    “In this holiday season, the best gift you can give yourself and to the members of your family, your loved ones, and friends is to get the booster – and bring some of them along when you get the vaccine so that they can get the booster also.”

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  • Long COVID Linked to More than 3,500 Deaths: CDC Report

    Long COVID Linked to More than 3,500 Deaths: CDC Report

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    Dec. 15, 2022 – More than 3,500 Americans died from long COVID during the first years of the pandemic, a new CDC report reveals. Men, people over 75, and American Indian/Alaska Native populations were at the highest risk of dying. 

    The CDC study is “certainly very sobering,” says William Schaffner, MD, a professor of medicine in the Division of Infectious Diseases at Vanderbilt University School of Medicine in Nashville.

    The new information shows that long COVID is more serious than many people previously considered, he says. “We know that long COVID is very common, and it’s causing a lot of grief for a lot of patients. Fortunately, over time, many of these patients improve.”

    However, “now we see from the CDC report that, actually, some people are going to die,” says Schaffner, who is also medical director of the National Foundation for Infectious Diseases. 

    Researchers at the CDC’s Center for Health Statistics looked at death certificates that mentioned long COVID (or chronic COVID, long haul COVID, post COVID syndrome, and others) as a cause of death or a contributing factor. They matched these certificates to medical records with a code related to COVID-19. 

    They identified 3,544 Americans who died from long COVID from Jan. 1, 2020, through June 30, 2022. This group is a fraction of the 1.02 million people who died from COVID-19 during that time. Their findings are published in the December 2022 CDC Vital Statistics Rapid Release report.

    “I think the study’s fascinating and interesting. It brings perspective to the consequences of COVID even after we’ve finished focusing on the acute infection itself,” says Thomas Gut, DO, associate chair of medicine and medical director of the Post-COVID Recovery Center at Staten Island University Hospital in New York City.

    It’s still early days, he says. “This is just the tip of the iceberg … for the consequences that we’re going to be facing long term.”

    Regarding the 3,500 deaths, “I think it’s a low number overall,” Gut says. “There’s probably a lot more people that have died. We probably missed a lot of long COVID early on, not realizing that’s what it was.”

    It’s unlikely death certificates earlier in the pandemic would include the acute COVID infection as a cause of death 3 to 6 months later, for example, Gut says. Going forward, this could change. Long COVID is a chronic condition, so it’s more likely to be listed on a death certificate. 

    Some at Higher Risk

    More than half of the deaths linked to long COVID, 57%, occurred in people ages 75 and older. Also, men accounted for 51.5% of long COVID deaths.

    Furthermore, 79% of long COVID deaths were non-Hispanic white people, followed by 10% non-Hispanic Black people and about 8% Hispanic people. 

    Even though non-Hispanic American Indian/Alaska Native people experienced less than 2% of all the long COVID deaths in the study, they emerged as a high-risk group in a separate analysis. Their age-adjusted death rate for long COVID was highest, at 14.8 deaths per 1 million people. In contrast, non-Hispanic Asian people had the lowest age-adjusted death rate, at 1.5 per 1 million.

    Minority groups like American Indians and Alaska Natives “have been disproportionately affected by the virus from the beginning of the pandemic – and have been also among the harder to reach and to provide access to the vaccine,” Schaffner says.

    This report shows that efforts to reach these underserved communities continues to be essential, he says. “We need to keep doing that – and if we needed another reason to do that, here it is.”

    The CDC researchers propose a bleak reason why higher death rates from long COVID were not found among non-Hispanic Black and Hispanic people in the study, despite these groups having higher COVID-19 mortality rates: Many COVID-19 patients in these groups likely died of their original disease before they could develop long COVID. 

    Some Study Limitations

    Although the medical community continues to learn and acknowledge the burden of long COVID and health care professionals have been using the term more, there is lots of variability, since we still do not a have a unified diagnosis of this illness . 

    “The fact that the number of long COVID labeled deaths has been increasing over time could be a result of more awareness among the medical community, and therefore make it very challenging to draw specific conclusions from this study,” says Fidaa Shaib, MD, an associate professor of medicine in the section of pulmonary, critical care, and sleep medicine, and director of the Post COVID Care Clinic at Baylor College of Medicine in Houston. 

    Even though the study found more deaths among men, “our experience and the experience of others have shown that PASC [post-acute sequelae of COVID] or long COVID patients are predominantly middle-aged women.”

    Shaib points out some limitations of the study. Some causes of long COVID deaths could be from other disorders – like heart disease – that increase the risk of death from acute COVID-19 itself. Also, the data did not include information about the length of time from the original COVID-19 illness to the time of death. “Therefore, the PASC/long COVID diagnosis might not be very accurate.”

    “Overall, this study is a good start to draw more attention about the seriousness of acute and long COVID illnesses,” Shaib says, “but more specific data is needed.”

    Keeping ‘the Pedal on the Metal’

    Avoiding COVID-19 in the first place remains the best protection against long COVID, Schaffner says. Like many public health officials, he emphasized the importance of staying up to date on COVID vaccinations as the most effective strategy. 

    “As a population, the United States has really not taken sufficient advantage of the freely available – and really quite effective – boosters that are out there now.” The latest CDC estimates report that 13.5% of Americans 5 years and older have received an updated booster dose. 

    For this reason, “we need to really to keep the pedal on the metal, trying to get the message out,” Schaffner says.

    “In this holiday season, the best gift you can give yourself and to the members of your family, your loved ones, and friends is to get the booster – and bring some of them along when you get the vaccine so that they can get the booster also.”

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  • Tiny, Menacing Microclots May Explain Long COVID’s Symptoms

    Tiny, Menacing Microclots May Explain Long COVID’s Symptoms

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    SOURCES:

    Hannah Davis, founding member and researcher, Patient-Led Research Collaborative.

    Etheresia (Resia) Pretorius, PhD, head of department and distinguished research professor, Physiological Sciences Department, Faculty of Science, Stellenbosch University, South Africa.

    Douglas Kell, PhD, research chair in systems biology, Department of Biochemistry, University of Liverpool, U.K.

    Michael VanElzakker, PhD, neuroscientist, Massachusetts General Hospital and Harvard Medical School; co-founder, PolyBio Research Foundation.

    Biochemical Journal: “A central role for amyloid fibrin microclots in long COVID/PASC: origins and therapeutic implications.”

    Preprint, medRxiv: “Prevalence of amyloid blood clots in COVID-19 plasma.”

    Cardiovascular Diabetology: Prevalence of symptoms, comorbidities, fibrin amyloid microclots and platelet pathology in individuals with Long COVID/Post-Acute Sequelae of COVID-19 (PASC).”

    Bioanalytical Sciences Group: “Long COVID and the role of fibrin amyloid (fibrinaloid) microclots.”

    U.S. Government Accountability Office: “Science and Tech Spotlight: Long Covid.”

    The Guardian: “Could microclots help explain the mystery of long Covid?”

    Frontiers in Microbiology: “Long COVID or Post-acute Sequelae of COVID-19 (PASC): An Overview of Biological Factors That May Contribute to Persistent Symptoms.”

    Nature Microbiology: “Metagenomic compendium of 189,680 DNA viruses from the human gut microbiome.”

    Bioscience Reports: “SARS-CoV-2 spike protein S1 induces fibrin(ogen) resistant to fibrinolysis: implications for microclot formation in COVID-19.”

    Clinical Infectious Diseases: “Persistent Circulating Severe Acute Respiratory Syndrome Coronavirus 2 Spike Is Associated With Post-acute Coronavirus Disease 2019 Sequelae.”

    YouTube: “The ‘Microclot’ Pathology of Long Covid With Dr Jaco Laubscher,” Gez Medinger:.

    Preprint, Research Square: “Combined triple treatment of fibrin amyloid microclots and platelet pathology in individuals with Long COVID/ Post-Acute Sequelae of COVID-19 (PASC) can resolve their persistent symptoms”

    The BMJ: “Long covid patients travel abroad for expensive and experimental ‘blood washing.’”

    Studies, Surveys and Supplements: “Frequently Asked Questions: Nattokinase, Lumbrokinase & Serrapeptase.”

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  • Tiny, Menacing Microclots May Explain Long COVID’s Symptoms

    Tiny, Menacing Microclots May Explain Long COVID’s Symptoms

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    Tiny, Menacing Microclots May Explain Long COVID’s Symptoms


    By
    Claire Sibonney
    WebMD Health News


    Dec. 7, 2022 – When Hannah Davis saw the first visual confirmation of long COVID in her blood – a firework-like display of fluorescent green dots against a black background – she was overwhelmed with an odd sense of relief. In early November, she became one of the first U.S. long COVID patients to be tested for microscopic blood clots, catching up to South Africa, Germany, the U.K., and other countries that are already experimenting with related treatments. 


    “It was validating,” says Davis, who excitedly shared the images of her clots on Twitter. “It’s basically the first test specific to long COVID that is promising and scientifically sound and incorporates research from other post-viral illnesses.”



    <blockquote class=”twitter-tweet”><p lang=”en” dir=”ltr”>Big news: I was lucky to get tested for micro blood clots, &amp; I have a lot of them! <a href=”https://twitter.com/hashtag/LongCovid?src=hash&amp;ref_src=twsrc%5Etfw”>#LongCovid</a><br><br>Healthy control blood on the left. Mine on the right. The green is all microclots!<br><br>These clots are likely blocking oxygen from getting around my body &amp; could explain many symptoms. 1/ <a href=”https://t.co/5rtuzN8D8f”>pic.twitter.com/5rtuzN8D8f</a></p>&mdash; Hannah Davis (@ahandvanish) <a href=”https://twitter.com/ahandvanish/status/1592626664131145728?ref_src=twsrc%5Etfw”>November 15, 2022</a></blockquote> <script async src=”https://platform.twitter.com/widgets.js” charset=”utf-8″></script>


    Davis donated her blood at Mount Sinai Hospital in New York City, with a few other founding members of the Patient-Led Research Collaborative, all of whom had been infected in the first wave of the pandemic and are still sick nearly 3 years later. Seeing the pictures of their blood clots, Davis and her fellow patients cried what she called happy tears. Then the reality of having those notorious blood clots sank in.


    Early in the COVID-19 pandemic, emergency room doctors and others treating patients noticed the sickest produced excessive blood clots. The clots clogged kidney dialysis machines, caused strokes, and killed patients long after they left the hospital. Some long COVID researchers have suspected smaller, less obvious blood clots may be causing many of the puzzling symptoms reported by patients who have lasting effects of the virus.


    The theory is that these weird and persistent clots, called microclots, might be blocking delicate blood vessels throughout the body, and stopping oxygen from getting to where it needs to go, causing everything from shortness of breath and organ damage to brain fog and debilitating fatigue. But if all the havoc is being done inside these minuscule clots, regular pathology tests won’t pick it up. A network of specialists is now setting out to see if specialized tests can be accessible and if the clots can be treated.

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  • Is It Long COVID, or Dementia, or Both?

    Is It Long COVID, or Dementia, or Both?

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    Nov. 28, 2022 – In early September, about a week after recovering from COVID-19, Barri Sanders went to the bank to pay a bill. But by mistake, she transferred a large amount of money from the wrong account. 

    “I’m talking about $20,000,” she says. “I had to go back [later] and fix it.”

    Sanders, 83, had not had confusion like that before. Suddenly, the Albuquerque, NM, resident found herself looking up from a book and not remembering what she had just read. She would stand up from her chair and forget what she meant to do. 

    “I kind of thought it was just the aging process,” she says. Combined with sudden balance issues, insomnia, and a nagging postnasal drip, the overall effect was “subtle, but scary,” she says.

    After 5 days of this, she went to bed and slept the whole night through. She woke up in the morning to find her balanced restored, her sinuses clear, and the mental fog gone. What she’d had, she realized, wasn’t a rapid start of dementia, but rather a mercifully short form of long COVID.

    Somewhere between 22% and 32% of people who recover from COVID-19 get “brain fog,” a non-scientific term used to describe slow or sluggish thinking. While this is disturbing at any age, it can be particularly upsetting to older patients and their caregivers, who fear they’re having or witnessing not just an after-effect of a disease, but the start of a permanent loss of thinking skills. And some scientists are starting to confirm what doctors, patients, and their families can already see: Older patients who have had COVID-19 have a higher risk of getting dementia or, if they already have mental confusion, the illness may worsen their condition. 

    British scientists who studied medical records from around the world reported in the journal The Lancet Psychiatry in August that people who recovered from COVID-19 had a higher risk of problems with their thinking and dementia even after 2 years had passed. 

    Another 2022 study, published in the journal JAMA Neurology, looked at older COVID-19 patients for a year after they were discharged from hospitals in Wuhan, China. Compared with uninfected people, those who survived a severe case of COVID-19 were at higher risk for early onset, late-onset, and progressive decline in their thinking skills. Those who survived a mild infection were at a higher risk for early onset decline, the study found. 

    Eran Metzger, MD, an assistant professor of psychiatry at Beth Israel Deaconess Medical Center in Boston, says he’s noticed that COVID-19 makes some older patients confused, and their brains don’t regain their former clarity. 

    “We see a stepwise decline in their cognition during the COVID episode, and then they never get back up to their baseline,” says Metzger, medical director at Hebrew SeniorLife. 

    New research is beginning to back up such findings. 

    People who got COVID-19 were twice as likely to receive a diagnosis of Alzheimer’s disease in the 12 months after infection, compared to those who didn’t get COVID, according to a study published in the journal Nature in September, which analyzed the health care databases of the U.S. Department of Veterans Affairs.

    Joshua Cahan, MD, a cognitive neurologist at Northwestern University, advises caution about applying such a specific label simply from a patient’s medical chart. After all, he notes, few patients get tested to confirm that they have the proteins linked to Alzheimer’s. 

    “Probably the most appropriate conclusion from that is that there’s an increased risk of dementia after a COVID infection,” he says, “but we don’t know whether it’s truly Alzheimer’s disease or not.”

    There could be a number of reasons why COVID-19 triggers a decline in thinking skills, says Michelle Monje, MD, a neuroscientist and neuro-oncologist at Stanford University.

    In a paper published in October in the journal Cell, Monje and her co-author, Akiko Iwasaki, PhD, a professor of immunobiology at Yale University, propose six possible triggers for brain fog caused by COVID: inflammation in the lungs and respiratory passages that leads to inflammation and dysregulation of the central nervous system; autoimmune reactions that damage the central nervous system; brain infection directly caused by the coronavirus (though, they note, this appears rare); a re-activation of a Epstein-Barr virus, which can lead to neuro-inflammation; triggered by the coronavirus; and/or complications from severe cases of COVID-19, possibly involving periods of low blood oxygen and multi-organ failure. 

    Scientific understanding of brain fog is “part of an emerging picture that inflammation elsewhere in the body can be transmitted to become inflammation in the brain,” Monje says. “And once there’s inflammation in the brain … that can dysregulate other cell types that normally support healthy cognitive function.”

    One issue with the concept of brain fog is that, like the term itself, the condition can be tough to define for doctors and patients alike and hard, if not impossible, to capture on common cognition tests. 

    These days, patients often arrive at the Center of Excellence for Alzheimer’s Disease, in Syracuse, NY, complaining that they “don’t feel the same” as they did before contracting COVID-19, says Sharon Brangman, MD, the center’s director and the chair of the Geriatrics Department at Upstate Medical University. 

    But the evidence of diminished cognition just isn’t there. 

    “There’s nothing that we can find, objectively, that’s wrong with them,” she says. “They’re not severe enough to score low on mental status testing.”

    But specialized, directed testing can find some probable signs, says Cahan, who evaluates patient cognition in a long COVID clinic at Northwestern University. 

    He often finds that his long COVID patients score in the low normal range on cognitive testing. 

    “Patients do have a complaint that something’s changed, and we don’t have prior testing,” he says. “So it’s possible that they were maybe in the high normal range or the superior range, but you just don’t know.”

    He says he has seen very high-performing people, like lawyers, executives, PhDs, and other professionals, who have tests that might be interpreted as normal, but given their level of achievement, “you would expect [higher scores].”

    Like Sanders, many of those who do have muddled thinking after a COVID infection return to their former mental status. A study published in the journal Brain Communications last January found that people who had recovered from COVID-19, even if they had a mild illness, were significantly more likely to have memory and other cognition issues in the months after infection. But after 9 months, the former COVID patients had returned to their normal level of cognition, the team at Britain’s University of Oxford reported.

    Notably, though, the average age of the people in the study was 28.6. 

    At the Northwestern clinic, Cahan treats patients who have struggled with COVID-induced cognition issues for months or even years. A rehabilitation program involves working with patients to come up with ways to compensate for cognitive deficits – such as making lists – as well as brain exercises, Cahan says. Over time, patients may achieve a 75% to 85% improvement, he says.

    Monje hopes that one day, science will come up with ways to fully reverse the decline. 

    “I think what is likely the most common contributor to brain fog is this neuro-inflammation, causing dysfunction of other cell types,” she says. “And, at least in the laboratory, we can rescue that in mouse models of chemotherapy brain fog, which gives me hope that we can rescue that for people.”

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  • A Growing List of Musicians Sidelined Due to Long COVID

    A Growing List of Musicians Sidelined Due to Long COVID

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    SOURCES: 

    Lungi Naidoo, singer songwriter, South Africa. 

    Twitter.com: @carseatheadrest, Oct. 18, 2022.

    David Putrino, PhD, director, Rehabilitation Innovation for the Mount Sinai Health System, New York City.

    Jason Maley, MD, director, Beth Israel Deaconess Medical Center’s Critical Illness and COVID-19 Survivorship Program.

    CDC: “Nearly One in Five American Adults Who Have Had COVID-19 Still Have “Long COVID””.

    StatPearls: “Post Acute Coronavirus (COVID-19) Syndrome.”

    Danny Zelisko, former chairman, Live Nation Southwest; owner, Danny Zelisko Presents.

    Lucas Sacks, director of booking, Brooklyn Bowl Williamsburg, Brooklyn Bowl Philadelphia.

    Joel Fram, Broadway conductor. 

    Grace McComsey, MD, leader, Long COVID RECOVER study, University Hospitals Health System, Cleveland.

    Terry Bell, singer songwriter, Nashville. 

    Jason Maley, MD, director, Beth Israel Deaconess Medical Center’s Critical Illness and COVID-19 Survivorship Program.

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  • Without Guidelines, Docs Make Their Own Long COVID Protocols

    Without Guidelines, Docs Make Their Own Long COVID Protocols

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    SOURCES:

    American Academy of Physical Medicine and Rehabilitation: “PASC Dashboard.”

    Janna Friedly, MD, executive director, Post-COVID Rehabilitation and Recovery Clinic, University of Washington.

    National Institutes of Health: “Coronavirus Disease 2019 (COVID-19) Treatment Guidelines,” “RECOVER: Researching COVID,” “RECOVER Program Takes First Steps in Advancing Toward Clinical Trials to Better Understand Long COVID.”

    Cancer: “Prevalence and Characteristics of Moderate to Severe Fatigue: A Multicenter Study in Cancer Patients and Survivors.”

    National Institute for Health Care and Excellence: “Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (or Encephalopathy): Diagnosis and Management.”

    Monica Verduzco-Gutierrez, MD, chair of rehabilitation medicine, director, COVID-19 Recovery Clinic, University of Texas Health Science Center at San Antonio.

    PM&R: “Multidisciplinary Collaborative Consensus Guidance Statement on the Assessment and Treatment of Fatigue in Postacute Sequelae of SARS-CoV-2 infection (PASC) Patients.”

    The Journal of Head Trauma Rehabilitation: “Effectiveness of Amantadine Hydrochloride in the Reduction of Chronic Traumatic Brain Injury Irritability and Aggression.”

    CNS Drugs: “Modafinil: A Review of its Pharmacology and Clinical Efficacy in the Management of Narcolepsy.”

    Frontiers in Neurology: “Methylphenidate Treatment of Cognitive Dysfunction in Adults After Mild to Moderate Traumatic Brain Injury: Rationale, Efficacy, and Neural Mechanisms.”

    PM&R: “Multi-Disciplinary Collaborative Consensus Guidance Statement on the Assessment and Treatment of Cognitive Symptoms in Patients With Post-Acute Sequelae of SARS-CoV-2 Infection (PASC).”

    Annals of Clinical and Translational Neurology: “Persistent Neurologic Symptoms and Cognitive Dysfunction in Non-Hospitalized Covid-19 Long Haulers.”

    Alba Miranda Azola, MD, co-director, Post-Acute COVID-19 Team, Johns Hopkins University School of Medicine, Baltimore.

    U.S. National Library of Medicine: “SARS-CoV-2 Viral Persistence Study (PASC) – Study of Long COVID-19.”

    PolyBio: “LongCovid Research Consortium.”

    Gary H. Gibbons, MD, director, National Heart, Lung, and Blood Institute.

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  • What Does It Mean to Care About COVID Anymore?

    What Does It Mean to Care About COVID Anymore?

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    After nearly three years of constantly thinking about COVID, it’s alarming how easily I can stop. The truth is, as a healthy, vaxxed-to-the-brim young person who has already had COVID, the pandemic now often feels more like an abstraction than a crisis. My perception of personal risk has dropped in recent months, as has my stamina for precautions. I still care about COVID, but I also eat in crowded cafés and go mask-free at parties.

    Heading into the third pandemic winter, things have changed. Most Americans seem to have tuned out COVID. Precautions have virtually disappeared; except for in the deepest-blue cities, wearing a mask is, well, weird. Reported cases are way down since the spring and summer, but perhaps the biggest reason for America’s behavioral let-up is that much of the country sees COVID as a minor nuisance, no more bothersome than a cold or the flu.

    And to a certain degree, they’re right: Most healthy, working-age adults who are up-to-date on their vaccinations won’t get severely ill—especially now that antivirals such as Paxlovid are available. Other treatments can help if a patient does get very sick. “People who are vaccinated and relatively healthy who are getting COVID are not getting that sick,” Lisa Lee, an epidemiologist at Virginia Tech, told me. “And so people are thinking, Wow, I’ve had COVID. It wasn’t that bad. I don’t really care anymore.”

    Still, there are many reasons to continue caring about COVID. About 300 people are still dying every day; COVID is on track to be the third-leading cause of death in the U.S. for the third year running. The prospect of developing long COVID is real and terrifying, as are mounting concerns about reinfections. But admittedly, these sometimes manifest in my mind as a dull, omnipresent horror, not an urgent affront. Continuing to care about COVID while also loosening up behaviors is an uncomfortable position to be in. Most of the time, I just try to ignore the guilt gnawing at my brain. At this point, when so few people feel that the potential benefit of dodging an infection is worth the inconvenience of precautions, what does it even mean to care about COVID?

    Read: Hundreds of Americans will die from COVID today

    In an ideal epidemiological scenario, everyone would willingly deploy the full arsenal of COVID precautions, such as masking and forgoing crowded indoor activities, especially during waves. But that kind of all-out response no longer makes sense. “It’s probably not realistic to expect people to take precautions every time, perpetually, or even every winter or fall, unless there is a particularly concerning reason to do that,” Jennifer Nuzzo, an epidemiologist at Brown University, told me.

    But, now more than ever, we must remember that COVID is not just a personal threat but a community one. For older and immunocompromised people, the risks are still significant. For example, people over 50 account for 93 percent of COVID-related deaths in the U.S., even though they represent just 35.7 percent of the population. As long as the death rate remains as high as it is, caring about COVID should mean orienting precautions to protect them. This idea has been around since the pandemic began, but its prominence faded as Americans put their personal health first. “If you’re otherwise healthy, it’s so easy just to think about yourself,” Lee said. “We have to think very carefully about that other part of infectious disease, which is the part where we can potentially hurt other people.”

    Orienting behavior in this way gives low-risk people a way to care about COVID that doesn’t entail constant masking or skipping all indoor activities: They can relax when they know they aren’t going to encounter vulnerable people. Like the productivity adage “work smarter, not harder,” this perspective allows people to take precautions strategically, not always. In practice, all it takes is some foresight. If you don’t live with vulnerable people, make it second nature to ask: Will I be seeing vulnerable people anytime soon? If the answer is no, do whatever you’re comfortable with given your own risk. If you are a healthy 30-something who lives alone, going to a Friendsgiving with other people your age is different from spending Thanksgiving dinner with parents and grandparents.

    If you will be seeing someone vulnerable, the most straightforward way to avoid giving them COVID is to avoid getting infected yourself, which means wearing a good mask in public settings and minimizing your interactions with others the week before, in what some experts have called a “mini-quarantine.” Not everyone has that luxury: Parents, for example, have to send their kids to school.

    Spontaneous interactions with vulnerable people are trickier to plan for, but they follow the same principle. On a crowded bus, for example, “there’s no question that if you’re close enough to someone who could be hurt by getting COVID and you could have it, then, yeah, a mask is the way to go,” Lee said. Of course, it isn’t always possible to know when someone is high-risk; young people, too, can be medically vulnerable. There’s no clear guidance for those situations, but remaining cautious doesn’t require much effort. “Carry a mask with you,” Lee said. “It’s not a big lift.”

    Get boosted—if not for yourself, then for them. Just 11.3 percent of eligible Americans have gotten the latest, bivalent shot, which potentially reduces your chances of getting COVID and passing it along. It also means getting tested, so you know when you’re infectious, and being aware of respiratory symptoms—of any kind. Alongside COVID, the flu and RSV are putting many people in the hospital, especially the very young and the very old. No matter how low your personal risk, if you have symptoms, avoiding transmission is crucial. “A reasonable thing to prioritize is: If you have symptoms, take care to prevent it from spreading,” Caitlin Rivers, an epidemiologist at Johns Hopkins University, told me.

    Read: It’s a bad time to be a booster slacker

    As we move away from a personal approach to COVID, we have an opportunity to expand the idea of what caring looks like. Low-risk people can, and should, take an active role in bolstering the protection of vulnerable people they know. In practical terms, this means ensuring that people in your life who are over 50—especially those over 65—are boosted and have a plan to get Paxlovid if they fall sick, Nuzzo said. “I think our biggest problem right now is that not everybody has enough access to the tools, and that’s a place where people can help.” She noted that she is particularly concerned about older people who struggle to book vaccine appointments online. Caring “doesn’t mean abstaining, per se. It means facilitating. It means enabling and helping people in your community.” This holiday season, caring could mean sitting down at a computer to make Grandma’s booster appointment, or driving her to the drugstore to get it.

    If you have lost your motivation to care about COVID, you might find it in the people you love. I didn’t feel a personal need to wear a mask at the concert I attended yesterday, but I did it because I don’t want to accidentally infect my partner’s 94-year-old grandfather when I see him next week. To have this experience of the pandemic is a privilege. Many don’t have the option to stop caring, even for a moment.

    Barring another Omicron-esque event, we thankfully won’t ever return to a moment where Americans obsess over COVID en masse. But this virus isn’t going away, so we can’t escape having a population that is split between the high-risk minority and the low-risk majority. Rethinking what it means to care allows for a more nuanced and liveable idea of what responsible behavior looks like. Right now, Nuzzo told me, the language we use to describe one’s position on COVID is “black-and-white, absolutist—you either care or you don’t.” There is space between those extremes. At least for now, it’s the only way to compromise between the world we have and the world we want.

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    Yasmin Tayag

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