ReportWire

Tag: pandemic began

  • Pfizer Couldn’t Pay for Marketing This Good

    Pfizer Couldn’t Pay for Marketing This Good

    On June 3, 2021, a roughly 60-year-old man in the riverside city of Magdeburg, Germany, received his first COVID vaccine. He opted for Johnson & Johnson’s shot, popular at that point because unlike Pfizer’s and Moderna’s vaccines, it was one-and-done. But that, evidently, was not what he had in mind. The following month, he got the AstraZeneca vaccine. The month after that, he doubled up on AstraZeneca and added a Pfizer for good measure. Things only accelerated from there: In January 2022, he received at least 49 COVID shots.

    A few months later, employees at a local vaccination center thought to themselves, Huh, wasn’t that guy in here yesterday? and alerted the police. By that point, the German Press Agency reported, the man had been vaccinated as many as 90 times. And still he was not done. As of November, he said he’d received 217 COVID shots—217!

    That’s according to a new paper published in The Lancet. After German researchers learned of the man from newspaper articles, they managed to contact him via the public prosecutor investigating the case. He was “very interested” in participating in a study Kilian Schober, an immunologist at Uniklinikum Erlangen and a co-author on the paper said in a statement. They pieced together his vaccination timeline through interviews and medical records, and collected blood and saliva samples to examine the immunological effects of “hypervaccination.”

    The man’s identity hasn’t been revealed, and in the paper he’s referred to only as “HIM” (seemingly an acronym, though what it stands for is not specified). He is hardly the world’s only hypervaccinated person. A retired postman in India had reportedly received 12 shots by January 2022 and told The New York Times, “I still want more.” A New Zealand man, meanwhile, allegedly racked up 10 in a single day. But pause for a moment and consider the sheer logistics of HIM’s feat. In all, he received his 217 vaccinations over the course of just under two and a half years, which comes out to an average of seven and a half shots a month, although the distribution was far from even. For several weeks in early 2022, he received two shots nearly every day. He seems to have had a strong preference for the Pfizer and Moderna vaccines, but he also got at least one shot of AstraZeneca and Sanofi-GSK and, of course, Johnson & Johnson.

    Why? you might wonder. The paper itself elides this question, saying only that he did so “deliberately and for private reasons.” Perhaps the most obvious explanation would be extreme, probably pathological COVID anxiety. News reports from April 2022 offer another possible explanation: that he did so to sell the vaccination cards. But German prosecutors did not bring charges once HIM’s scheme was uncovered, and he continued getting unnecessary shots.

    Getting 217 COVID shots is very much not the public-health guidance in Germany or anywhere else. Yet the strategy seemingly panned out: HIM has never contracted COVID, researchers concluded based on antigen tests, PCR tests, and bloodwork. “If you ask immunologists, we might have predicted that it would be not beneficial to do this,” Cindy Leifer, an immunologist at Cornell University who wasn’t involved with the Lancet study, told me. They might have expected the constant action to exhaust the immune system, leaving it vulnerable to actual viral threats. But such worries came to nothing.

    Still, immunologists cautioned against inferring any strong causal connection. He avoided the virus; he got vaccinated 217 times. He did not necessarily avoid the virus because he got vaccinated 217 times. In fact, the authors wrote, although hypervaccination seems to have increased the quantity of antibodies and T cells that HIM’s body produced to fend off the virus—even after 216 shots, the 217th still produced a modest increase—it had no real effect on the quality of the immune response. “He would have been just as well protected if he had gotten a normal number of three to four vaccinations,” Schober told me.

    Nor did hypervaccination lead to any adverse effects. By shot 217, one might have expected to see some of the rare side effects associated with the vaccines, such as myocarditis, pericarditis, or Guillain-Barré Syndrome, but as far as researchers could tell, HIM was completely fine. Remarkably, he didn’t even report feeling minor side effects from any of his 217 shots. On some level, this makes total sense: As Schober reasonably pointed out, HIM probably would not have gotten all those shots if each one had knocked him out for a day. Fair, but still: 217 shots and no side effects? How?

    If nothing else, HIM is one hell of an advertisement for the vaccines. Worried about side effects from your third booster? Well, this guy’s gotten more than 200, and he’s a-okay. Travis Kelce has been called Mr. Pfizer, but he’s got nothing on HIM. Scientifically, things are somewhat murkier. The results of the HIM study were largely unsurprising, researchers told me, but the mysteries at the margins—such as the absence of any side effects—are a good reminder that four years after the pandemic began, immunology is still, as my former colleague Ed Yong wrote, “where intuition goes to die.”

    At the end of the paper, the authors are very clear: “We do not endorse hypervaccination as a strategy to enhance adaptive immunity.” The takeaway, Leifer said, should not be the more shots, the better. Schober told me he even tried to personally convey this message to HIM after his 216th shot. “From the bottom of my heart as a medical doctor, I really told him that he shouldn’t get vaccinated again,” Schober said.

    HIM seemed to take this advice seriously. Then he went and got shot No. 217 anyway.

    Jacob Stern

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  • Flu Shots Need to Stop Fighting ‘Something That Doesn’t Exist’

    Flu Shots Need to Stop Fighting ‘Something That Doesn’t Exist’


    Listen to this article

    Produced by ElevenLabs and NOA, News Over Audio, using AI narration.

    In Arnold Monto’s ideal vision of this fall, the United States’ flu vaccines would be slated for some serious change—booting a major ingredient that they’ve consistently included since 2013. The component isn’t dangerous. And it made sense to use before. But to include it again now, Monto, an epidemiologist and a flu expert at the University of Michigan, told me, would mean vaccinating people “against something that doesn’t exist.”

    That probably nonexistent something is Yamagata, a lineage of influenza B viruses that hasn’t been spotted by global surveyors since March of 2020, shortly after COVID mitigations plummeted flu transmission to record lows. “And it isn’t for lack of looking,” Kanta Subbarao, the director of the WHO’s Collaborating Centre for Reference and Research on Influenza, told me. In a last-ditch attempt to find the missing pathogen, a worldwide network of monitoring centers tested nearly 16,000 influenza B virus samples collected from February to August of last year. Not a single one of them came up Yamagata. “The consensus is that it’s gone,” Cheryl Cohen, the head of South Africa’s Centre for Respiratory Diseases and Meningitis, told me. Officially removing an ingredient from flu vaccines will codify that sentiment, effectively publishing Yamagata’s obituary.

    Read: The flu may never be the same

    Last year around this time, Subbarao told me, the WHO was already gently suggesting that the world might want to drop Yamagata from vaccines; by September, the agency had grown insistent, describing the ingredient as “no longer warranted” and urging that “every effort should be made to exclude it as soon as possible.” The following month, an advisory committee to the FDA unanimously voted to speedily adopt that same change.

    But the switch from a four-flu vaccine to a trivalent one, guarding against only three, isn’t as simple as ordering the usual, please, just hold the Yams. Trivalent vaccines require their own licensure, which some manufacturers may have allowed to lapse—or never had at all; manufacturers must also adhere to the regulatory pipelines specific to each country. “People think, ‘They change the strains every season; this should be no big deal,’” Paula Barbosa, the associate director of vaccine policy at the International Federation of Pharmaceutical Manufacturers and Associations, which represents vaccine manufacturers, told me. This situation is not so simple: “They need to change their whole manufacturing process.” At the FDA advisory-committee meeting in October, an industry representative cautioned that companies might need until the 2025–26 season to fully transition to trivalents in the Northern Hemisphere, a timeline that Barbosa, too, considers realistic. The South could take until 2026.

    In the U.S., though, where experts such as Monto have been pushing for expedient change, a Yamagata-less flu vaccine could be coming this fall. When I reached out to CSL Seqirus and GSK, two of the world’s major flu-vaccine producers, a spokesperson from each company told me that their firm was on track to deliver trivalent vaccines to the U.S. in time for the 2024–25 flu season, should the relevant agencies recommend and request it. (The WHO’s annual meeting to recommend the composition of the Northern Hemisphere’s flu vaccine isn’t scheduled until the end of February; an FDA advisory meeting on the same topic will follow shortly after.) Sanofi, another vaccine producer, was less definitive, but told me that, with sufficient notice from health authorities, its plans would allow for trivalent vaccines this year, “if there is a definitive switch.” AstraZeneca, which makes the FluMist nasal-spray vaccine, told me that it was “engaging with the appropriate regulatory bodies” to coordinate the shift to a trivalent vaccine “as soon as possible.”

    Quadrivalent flu vaccines are relatively new. Just over a decade ago, the world relied on immunizations that included two flu A strains (H1N1 and H3N2), plus one B: either Victoria or Yamagata, whichever scientists predicted might be the bigger scourge in the coming flu season. “Sometimes the world got it wrong,” Mark Jit, an epidemiologist at the London School of Hygiene & Tropical Medicine, told me. To hedge their bets, experts eventually began to recommend simply sticking in both. But quadrivalent vaccines typically cost more to manufacture, experts told me. And although several countries, including the U.S., quickly transitioned to the heftier shots, many nations—especially those with fewer resources—never did.

    Now “the extra component is a waste,” Vijay Dhanasekaran, a virologist at the University of Hong Kong, told me. It’s pointless to ask people’s bodies to mount a defense against an enemy that will never attack. Trimming Yamagata out of flu-vaccine recipes should also make them cheaper, Dhanasekaran said, which could improve global access. Plus, continuing to manufacture Yamagata-focused vaccines raises the small but serious risk that the lineage could be inadvertently reintroduced to the world, Subbarao told me, as companies grow gobs of the virus for their production pipeline. (Some vaccines, such as FluMist, also immunize people with live-but-weakened versions of flu viruses.)

    Some of the researchers I spoke with for this article weren’t ready to rule out the possibility—however slim—that Yamagata is still biding its time somewhere. (Victoria, a close cousin of Yamagata, and the other B lineage that pesters people, once went mostly quiet for about a decade, before roaring back in the early aughts.) But most experts, at this point, are quite convinced. The past couple of flu seasons have been heavy enough to offer even a rather rare lineage the chance to reappear. “If it had been circulating in any community, I’m pretty sure that global influenza surveillance would have detected it by now,” Dhanasekaran said. Plus, even before the pandemic began, Yamagata had been the wimpiest of the flu bunch, Jit told me: slow to evolve, crummy at transmitting, and already dipping in prevalence. When responses to the pandemic starved all flu viruses of hosts, he said, this lineage was the likeliest to be lost.

    Read: The pandemic broke the flu

    Eventually, companies may return to including four types of flu in their products, swapping in, say, another strain of H3N2, the most severe and fastest-evolving of the bunch—a change that Subbarao and Monto both told me might actually be preferable. But incorporating a second H3N2 is even more of a headache than returning to a trivalent vaccine: Researchers would likely first need to run clinical trials, experts told me, to ensure that the new components played nicely with each other and conferred additional benefits.

    For the moment, a slimmed-down vaccine is the quickest way to keep up with the flu’s current antics. And in doing so, those vaccines will also reflect the strange reality of this new, COVID-modified world. “A whole lineage of flu has probably been eliminated through changes in human behavior,” Jit told me. Humanity may not have intended it. But our actions against one virus may have forever altered the course of another.



    Katherine J. Wu

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  • The Big COVID Question for Hospitals This Fall

    The Big COVID Question for Hospitals This Fall

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

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

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

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

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

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

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

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

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

    Read: The future of long COVID

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

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

    Read: What COVID hospitalization numbers are missing

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

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

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

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

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

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

    Read: The pandemic’s legacy is already clear

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

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

    Katherine J. Wu

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  • A Major Clue to COVID’s Origins Is Just Out of Reach

    A Major Clue to COVID’s Origins Is Just Out of Reach

    Updated at 2:45 p.m. on March 21, 2023

    Last week, the ongoing debate about COVID-19’s origins acquired a new plot twist. A French evolutionary biologist stumbled across a trove of genetic sequences extracted from swabs collected from surfaces at a wet market in Wuhan, China, shortly after the pandemic began; she and an international team of colleagues downloaded the data in hopes of understanding who—or what—might have ferried the virus into the venue. What they found, as The Atlantic first reported on Thursday, bolsters the case for the pandemic having purely natural roots: The genetic data suggest that live mammals illegally for sale at the Huanan Seafood Wholesale Market—among them, raccoon dogs, a foxlike species known to be susceptible to the virus—may have been carrying the coronavirus at the end of 2019.

    But what might otherwise have been a straightforward story on new evidence has rapidly morphed into a mystery centered on the origins debate’s data gaps. Within a day or so of nabbing the sequences off a database called GISAID, the researchers told me, they reached out to the Chinese scientists who had uploaded the data to share some preliminary results. The next day, public access to the sequences was locked—according to GISAID, at the request of the Chinese researchers, who had previously analyzed the data and drawn distinctly different conclusions about what they contained.

    Read: The strongest evidence yet that an animal started the pandemic

    Yesterday evening, the international team behind the new Huanan-market analysis released a report on its findings—but did not post the underlying data. The write-up confirms that genetic material from raccoon dogs and several other mammals was found in some of the same spots at the wet market, as were bits of SARS-CoV-2’s genome around the time the outbreak began. Some of that animal genetic material, which was collected just days or weeks after the market was shut down, appears to be RNA—a particularly fast-degrading molecule. That strongly suggests that the mammals were present at the market not long before the samples were collected, making them a plausible channel for the virus to travel on its way to us. “I think we’re moving toward more and more evidence that this was an animal spillover at the market,” says Ravindra Gupta, a virologist at the University of Cambridge, who was not involved in the new research. “A year and a half ago, my confidence in the animal origin was 80 percent, something like that. Now it’s 95 percent or above.”

    For now, the report is just that: a report, not yet formally reviewed by other scientists or even submitted for publication to the journal—and that will remain the case as long as this team continues to leave space for the researchers who originally collected the market samples, many of them based at the Chinese Center for Disease Control and Prevention, to prepare a paper of their own. And still missing are the raw sequence files that sparked the reanalysis in the first place—before vanishing from the public eye.

    Every researcher I asked emphasized just how important the release of that evidence is to the origins investigation: Without data, there’s no base-level proof—nothing for the broader scientific community to independently scrutinize to confirm or refute the international team’s results. Absent raw data, “some people will say that this isn’t real,” says Gigi Gronvall, a senior scholar at the Johns Hopkins Center for Health Security, who wasn’t involved in the new analysis. Data that flicker on and off publicly accessible parts of the internet also raise questions about other clues on the pandemic’s origins. Still more evidence might be out there, yet undisclosed.

    Transparency is always an essential facet of research, but all the more so when the stakes are so high. SARS-CoV-2 has already killed nearly 7 million people, at least, and saddled countless people with chronic illness; it will kill and debilitate many more in the decades to come. Every investigation into how it began to spread among humans must be “conducted as openly as possible,” says Sarah Cobey, an infectious-disease modeler at the University of Chicago, who wasn’t involved in the new analysis.

    The team behind the reanalysis still has copies of the genetic sequences its members downloaded earlier this month. But they’ve decided that they won’t be the ones to share them, several of them told me. For one, they don’t have sequences from the complete set of samples that the Chinese team collected in early 2020—just the fraction that they spotted and grabbed off GISAID. Even if they did have all of the data, the researchers contend that it’s not their place to post them publicly. That’s up to the China CDC team that originally collected and generated the data.

    Part of the international team’s reasoning is rooted in academic decorum. There isn’t a set-in-stone guidebook among scientists, but adhering to unofficial rules on etiquette smooths successful collaborations across disciplines and international borders—especially during a global crisis such as this one. Releasing someone else’s data, the product of another team’s hard work, is a faux pas. It risks misattribution of credit, and opens the door to the Chinese researchers’ findings getting scooped before they publish a high-profile paper in a prestigious journal. “It isn’t right to share the original authors’ data without their consent,” says Niema Moshiri, a computational biologist at UC San Diego and one of the authors of the new report. “They produced the data, so it’s their data to share with the world.”

    If the international team released what data it has, it could potentially stoke the fracas in other ways. The World Health Organization has publicly indicated that the data should come from the researchers who collected them first: On Friday, at a press briefing, Tedros Adhanom Ghebreyesus, the WHO’s director-general, admonished the Chinese researchers for keeping their data under wraps for so long, and called on them to release the sequences again. “These data could have and should have been shared three years ago,” he said. And the fact that it wasn’t is “disturbing,” given just how much it might have aided investigations early on, says Gregory Koblentz, a biodefense expert at George Mason University, who wasn’t involved in the new analysis.

    Publishing the current report has already gotten the researchers into trouble with GISAID, the database where they found the genetic sequences. During the pandemic, the database has been a crucial hub for researchers sharing viral genome data; founded to provide open access to avian influenza genomes, it is also where researchers from the China CDC published the first whole-genome sequences of SARS-CoV-2, back in January 2020. A few days after the researchers downloaded the sequences, they told me, several of them were contacted by a GISAID administrator who chastised them about not being sufficiently collaborative with the China CDC team and warned them against publishing a paper using the China CDC data. They were in danger, the email said, of violating the site’s terms of use and would risk getting their database access revoked. Distributing the data to any non-GISAID users—including the broader research community—would also be a breach.

    This morning, hours after the researchers released their report online, many of them found that they could no longer log in to GISAID—they received an error message when they input their username and password. “They may indeed be accusing us of having violated their terms,” Moshiri told me, though he can’t be sure. The ban was instated with absolutely no warning. Moshiri and his colleagues maintain that they did act in good faith and haven’t violated any of the database’s terms—that, contrary to GISAID’s accusations, they reached out multiple times with offers to collaborate with the China CDC, which has “thus far declined,” per the international team’s report.

    GISAID didn’t respond when I reached out about the data’s disappearing act, its emails to the international team, and the group-wide ban. But in a statement released shortly after I contacted the database—one that echoes language in the emails sent to researchers—GISAID doubled down on accusing the international team of violating its terms of use by posting “an analysis report in direct contravention of the terms they agreed to as a condition to accessing the data, and despite having knowledge that the data generators are undergoing peer review assessment of their own publication.”

    Maria Van Kerkhove, the WHO’s COVID-19 technical lead, told me that she’s learned that the China CDC researchers recently provided a fuller data set to GISAID—more complete than the one the international team downloaded earlier this month. “It’s ready to go,” she told me. GISAID just needs permission, she said, from the Chinese researchers to make the sequences publicly available. “I reach out to them every day, asking them for a status update,” she added, but she hasn’t yet heard back on a definitive timeline. In its statement, GISAID also “strongly” suggested “that the complete and updated dataset will be made available as soon as possible,” but gave no timeline. I asked Van Kerkhove if there was a hypothetical deadline for the China CDC team to restore access, at which point the international team might be asked to publicize the data instead. “This hypothetical deadline you’re talking about? We’re way past that,” she said, though she didn’t comment specifically on whether the international team would be asked to step in. “Data has been uploaded. It is available. It just needs to be accessible, immediately.”

    Why, exactly, the sequences were first made public only so recently, and why they have yet to reappear publicly, remain unclear. In a recent statement, the WHO said that access to the data was withdrawn “apparently to allow further data updates by China CDC” to its original analysis on the market samples, which went under review for publication at the journal Nature last week. There’s no clarity, however, on what will happen if the paper is not published at all. When I reached out to three of the Chinese researchers—George Gao, William Liu, and Guizhen Wu—to ask about their intentions for the data, I didn’t receive a response.

    “We want the data to come out more than anybody,” says Saskia Popescu, an infectious-disease epidemiologist at George Mason University and one of the authors on the new analysis. Until then, the international team will be fielding accusations, already flooding in, that it falsified its analyses and overstated its conclusions.

    Researchers around the world have been raising questions about these particular genetic sequences for at least a year. In February 2022, the Chinese researchers and their close collaborators released their analysis of the same market samples probed in the new report, as well as other bits of genetic data that haven’t yet been made public. But their interpretations deviate pretty drastically from the international team’s. The Chinese team contended that any shreds of virus found at the market had most likely been brought in by infected humans. “No animal host of SARS-CoV-2 can be deduced,” the researchers asserted at the time. Although the market had perhaps been an “amplifier” of the outbreak, their analysis read, “more work involving international coordination” would be needed to determine the “real origins of SARS-CoV-2.” When reached by Jon Cohen of Science magazine last week, Gao described the sequences that fleetingly appeared on GISAID as “[n]othing new. It had been known there was illegal animal dealing and this is why the market was immediately shut down.”

    There is, then, a clear divergence between the two reports. Gao’s assessment indicates that finding animal genetic material in the market swabs merely confirms that live mammals were being illegally traded at the venue prior to January 2020. The researchers behind the new report insist that the narrative can now go a step further—they suggest not just that the animals were there, but that the animals, several of which are already known to be vulnerable to SARS-CoV-2, were there, in parts of the market where the virus was also found. That proximity, coupled with the virus’s inability to persist without a viable host, points to the possibility of an existing infection among animals, which could spark several more.

    The Chinese researchers used this same logic of location—multiple types of genetic material pulled out of the same swab—to conclude that humans were carrying around the virus at Huanan. The reanalysis confirms that there probably were infected people at the market at some point before it closed. But they were unlikely to be the virus’s only chauffeurs: Across several samples, the amount of raccoon-dog genetic material dwarfs that of humans. At one stall in particular—located in the sector of the market where the most virus-positive swabs were found—the researchers discovered at least one sample that contained SARS-CoV-2 RNA, and was also overflowing with raccoon-dog genetic material, while containing very little DNA or RNA material matching the human genome. That same stall was photographically documented housing raccoon dogs in 2014. The case is not a slam dunk: No one has yet, for instance, identified a viral sample taken from a live animal that was swabbed at the market in 2019 before the venue was closed. Still, JHU’s Gronvall told me, the situation feels clearer than ever. “All of the science is pointed” in the direction of Huanan being the pandemic’s epicenter, she said.

    To further untangle the significance of the sequences will require—you guessed it—the now-vanished genetic data. Some researchers are still withholding their judgment on the significance of the new analysis, because they haven’t gotten their hands on the genetic sequences themselves. “That’s the whole scientific process,” Van Kerkhove told me: data transparency that allows analyses to be “done and redone.”

    Van Kerkhove and others are also wondering whether more data could yet emerge, given how long this particular set went unshared. “This is an indication to me in recent days that there is more data that exists,” she said. Which means that she and her colleagues haven’t yet gotten the fullest picture of the pandemic’s early days that they could—and that they won’t be able to deliver much of a verdict until more information emerges. The new analysis does bolster the case for market animals acting as a conduit for the virus between bats (SARS-CoV-2’s likeliest original host, based on several studies on this coronavirus and others) and people; it doesn’t, however, “tell us that the other hypotheses didn’t happen. We can’t remove any of them,” Van Kerkhove told me.

    More surveillance for the virus needs to be done in wild-animal populations, she said. Having the data from the market swabs could help with that, perhaps leading back to a population of mammals that might have caught the virus from bats or another intermediary in a particular part of China. At the same time, to further investigate the idea that SARS-CoV-2 first emerged out of a laboratory mishap, officials need to conduct intensive audits and investigations of virology laboratories in Wuhan and elsewhere. Last month, the U.S. Department of Energy ruled that such an accident was the likelier catalyst of the coronavirus outbreak than a natural spillover from wild animals to humans. The ruling echoed earlier judgments from the FBI and a Senate minority report. But it contrasted with the views of four other agencies, plus the National Intelligence Council, and it was made with “low confidence” and based on “new” evidence that has yet to be declassified.

    Read: The lab leak will haunt us forever

    The longer the investigation into the virus’s origins drags on, and the more distant the autumn of 2019 grows in our rearview, “the harder it becomes,” Van Kerkhove told me. Many in the research community were surprised that new information from market samples collected in early 2020 emerged at all, three years later. Settling the squabbles over SARS-CoV-2 will be especially tough because the Huanan market was so swiftly shut down after the outbreak began, and the traded animals at the venue rapidly culled, says Angela Rasmussen, a virologist at the University of Saskatchewan and one of the researchers behind the new analysis. Raccoon dogs, one of the most prominent potential hosts to have emerged from the new analysis, are not even known to have been sampled live at the market. “That evidence is gone now,” if it ever existed, Koblentz, of George Mason University, told me. For months, Chinese officials were even adamant that no mammals were being illegally sold at the region’s wet markets at all.

    So researchers continue to work with what they have: swabs from surfaces that can, at the very least, point to a susceptible animal being in the right place, at the right time, with the virus potentially inside it. “Right now, to the best of my knowledge, this data is the only way that we can actually look,” Rasmussen told me. It may never be enough to fully settle this debate. But right now, the world doesn’t even know the extent of the evidence available—or what could, or should, still emerge.

    Katherine J. Wu

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  • Are Colds Really Worse, or Are We All Just Weak Babies Now?

    Are Colds Really Worse, or Are We All Just Weak Babies Now?

    For the past few weeks, my daily existence has been scored by the melodies of late winter: the drip of melting ice, the soft rustling of freshly sprouted leaves—and, of course, the nonstop racket of sneezes and coughs.

    The lobby of my apartment building is alive with the sounds of sniffles and throats being cleared. Every time I walk down the street, I’m treated to the sight of watery eyes and red noses. Even my work Slack is rife with illness emoji, and the telltale pings of miserable colleagues asking each other why they feel like absolute garbage. “It’s not COVID,” they say. “I tested, like, a million times.” Something else, they insist, is making them feel like a stuffed and cooked goose.

    That something else might be the once-overlooked common cold. After three years of largely being punted out of the limelight, a glut of airway pathogens—among them, adenovirus, RSV, metapneumovirus, parainfluenza, common-cold coronaviruses, and rhinoviruses galore—are awfully common again. And they’re really laying some people out. The good news is that there’s no evidence that colds are actually, objectively worse now than they were before the pandemic started. The less-good news is that after years of respite from a bunch of viral nuisances, a lot of us have forgotten that colds can be a real drag.

    Read: The pandemic broke the flu … again

    Once upon a time—before 2020, to be precise—most of us were very, very used to colds. Every year, adults, on average, catch two to three of the more than 200 viral strains that are known to cause the illnesses; young kids may contract half a dozen or more as they toddle in and out of the germ incubators that we call “day cares” and “schools.” The sicknesses are especially common during the winter months, when many viruses thrive amid cooler temps, and people tend to flock indoors to exchange gifts and breath. When the pandemic began, masks and distancing drove several of those microbes into hiding—but as mitigations have eased in the time since, they’ve begun their slow creep back.

    For the majority of people, that’s not really a big deal. Common-cold symptoms tend to be pretty mild and usually resolve on their own after a few days of nuisance. The virus infiltrates the nose and throat, but isn’t able to do much damage and gets quickly swept out. Some people may not even notice they’re infected at all, or may mistake the illness for an allergy—snottiness, drippiness, and not much more. Most of us know the drill: “Sometimes, it’s just congestion for a few days and feeling a bit tired for a while, but otherwise you’ll be just fine,” says Emily Landon, an infectious-disease physician at the University of Chicago. As a culture, we’ve long been in the habit of dismissing these symptoms as just a cold, not enough of an inconvenience to skip work or school, or to put on a mask. (Spoiler: The experts I spoke with were adamant that we all really should be doing those things when we have a cold.)

    The general infectious-disease dogma has always been that colds are a big nothing, at least compared with the flu. But gentler than the flu is not saying much. The flu is a legitimately dangerous disease that hospitalizes hundreds of thousands of Americans each year, and, like COVID, can sometimes saddle people with long-term symptoms. Even if colds are generally less severe, people can end up totally clobbered by headaches, exhaustion, and a burning sore throat; their eyes will tear up; their sinuses will clog; they’ll wake up feeling like they’ve swallowed serrated razor blades, or like their heads have been pumped full of fast-hardening concrete. It’s also common for cold symptoms to stretch out beyond a week, occasionally even two; coughs, especially, can linger long after the runny nose and headache resolve. At their worst, colds can lead to serious complications, especially in the very young, very old, and immunocompromised. Sometimes, cold sufferers end up catching a bacterial infection on top of their viral disease, a one-two punch that can warrant a trip to the ER. “The fact of the matter is, it’s pretty miserable to have a cold,” Landon told me. “And that’s how it’s always been.”

    Read: Don’t worry, it’s not COVID

    As far as experts can tell, the average severity of cold symptoms hasn’t changed. “It’s about perception,” says Jasmine Marcelin, an infectious-disease physician at the University of Nebraska Medical Center. After skipping colds for several years, “experiencing them now feels worse than usual,” she told me. Frankly, this was sort of a problem even before COVID came onto the scene. “Every year, I have patients who call me with ‘the worst cold they’ve ever had,’” Landon told me. “And it’s basically the same thing they had last year.” Now, though, the catastrophizing might be even worse, especially since pandemic-brain started prompting people to scrutinize every sniffle and cough.

    There’s still a chance that some colds this season might be a shade more unpleasant than usual. Many people falling sick right now are just coming off of bouts with COVID, flu, or RSV, each of which infected Americans (especially kids) by the millions this past fall and winter. Their already damaged tissues may not fare as well against another onslaught from a cold-causing virus.

    It’s also possible that immunity, or lack thereof, could be playing a small role. Many people are now getting their first colds in three-plus years, which means population-level vulnerability might be higher than it normally is this time of year, speeding the rate at which viruses spread and potentially making some infections more gnarly than they’d otherwise be. But higher-than-usual susceptibility seems unlikely to be driving uglier symptoms en masse, says Roby Bhattacharyya, an infectious-disease physician and microbiologist at Massachusetts General Hospital. Not all cold-causing viruses leave behind good immunity—but many of those that do are thought to prompt the body to mount relatively durable defenses against truly severe infections, lasting several years or more.

    Plus, for a lot of viruses going around right now, the immunity question is largely moot, Landon told me. So many different pathogens cause colds that a recent exposure to one is unlikely to do much against the next. A person could catch half a dozen colds in a five-year time frame and not even encounter the same type of virus twice.

    Read: Maybe consider not kissing that baby

    It’s also worth noting that what some people are categorizing as the worst cold they’ve ever had might actually be a far more menacing virus, such as SARS-CoV-2 or a flu virus. At-home rapid tests for the coronavirus often churn out false-negative results in the early days of infection, even after symptoms start. And although the flu can sometimes be distinguished from a cold by its symptoms, they’re often pretty similar. The illnesses can only be definitively diagnosed with a test, which can be difficult to come by.

    The pandemic has steered our perception of illness into a false binary: Oh no, it’s COVID or Phew, it’s not. COVID is undoubtedly still more serious than a run-of-the-mill cold—more likely to spark severe disease or chronic, debilitating symptoms that can last months or years. But the range of severity between them overlaps more than the binary implies. Plus, Marcelin points out, what truly is “just” a cold for one person might be an awful, weeks-long slog for someone else, or worse—which is why, no matter what’s turning your face into a snot factory, it’s still important to keep your germs to yourself. The current outbreak of colds may not be any more severe than usual. But there’s no need to make it bigger than it needs to be.

    Katherine J. Wu

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  • The Future of Long COVID

    The Future of Long COVID

    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.

    Katherine J. Wu

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  • What Does It Mean to Care About COVID Anymore?

    What Does It Mean to Care About COVID Anymore?

    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.

    Yasmin Tayag

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  • The Pandemic Forced the World to Pay Attention to Oxygen

    The Pandemic Forced the World to Pay Attention to Oxygen

    A version of this article was originally published in Undark Magazine.

    On a late April afternoon, the Ngor Health Center in Dakar, Senegal, is serene. Sunlight spills through architectural gaps in the ceiling and lush plants line cream-colored corridors. In a patient waiting area on the second floor, a staff member gently rolls a ball back and forth with a toddler.

    The calm belies the chaos at the health center eight months prior, in the summer of 2021, when COVID-19 struck the West African nation in its third and deadliest wave. The only reminder exists high up on the walls: slim copper pipes trained through roughly drilled holes. The pipes were built as Ngor frantically retrofitted its waiting area with extra beds in a bid to extend the center’s limited oxygen network to treat the influx of COVID patients.

    But to the pediatrician Idrissa Demba Ba, the scramble for oxygen—which, in many countries, came to symbolize the pandemic—was nothing new. In fact, it’s a hallmark of another scourge he’s been battling for 18 years, childhood pneumonia. The disease, caused by an infection of the lungs that disrupts breathing, killed 2,400 Senegalese children under the age of 5 in 2019.

    Pneumonia can be triggered when a pathogen—for instance, a virus, bacteria, or fungus—enters the lungs, where it inflames the air sacs, causing them to fill with fluid or pus and making it hard to breathe. Children are more vulnerable to the disease because their lungs and immune systems are still developing. To treat the condition, there are three main options: antibiotics, antivirals, and oxygen. Every day, there are children who need to be connected to an oxygen supply, says Ba, who is head of pediatric pulmonology at Dakar’s Albert Royer National Children’s Hospital.

    The World Health Organization lists oxygen as an essential medicine, which seems intuitive for a vital, life-sustaining gas. Yet in Senegal and many other developing countries, providing oxygen in its medical form can be fraught: The medical-grade oxygen is expensive, getting it from one place to another requires the construction of pipelines and other infrastructure, and medical personnel must be trained to administer it.

    These supply-chain obstacles threaten, per one estimate, more than 7 million children in low- and middle-income countries who are infected with pneumonia each year and need oxygen to survive. Limited supplies are part of the reason the disease remains the most common infectious cause of death in children worldwide, claiming the lives of more than 740,000 under the age of 5 in 2019. Younger children are more vulnerable—29 percent of pneumonia deaths occur within the first month of life, and three-quarters within the first year.

    Most of those affected live in lower- and middle-income countries like Senegal, where the risk of pneumonia is exacerbated by malnutrition and other issues, says Papa Birane Mbodji, the head of newborn health at the Department of Mother and Child Health in Senegal’s Ministry of Health and Social Action. Another threat is the nearby Sahara Desert, which sweeps in huge amounts of dust that contribute to the region’s outsize global burden of young patients.

    When there isn’t enough oxygen to treat these children, their lungs fail, eliciting grunts as they try desperately to rake in more oxygen from the air, Ba says—a symptom that echoes the devastating effects of COVID-19. While the world’s attention has been trained on COVID, “you could basically say there is an ongoing pandemic of pneumonia mortality,” says Keith Klugman, an infectious-disease expert who heads the pneumonia program at the Bill and Melinda Gates Foundation.

    But there may be an upside: The crisis of the coronavirus pandemic drew the world’s attention to the crucial importance of oxygen. Seeing how quickly countries galvanized to tackle COVID, Klugman and other experts wrote a Lancet article in November 2020, calling for them to build on the pandemic’s rare gains—such as increasing oxygen infrastructure—to help curb childhood pneumonia. The authors wrote: “The COVID-19 response provides opportunities to increase diagnostic and treatment services for respiratory infections.”

    Ba and other experts on the ground share the sentiment. More and more, they see COVID as an opportunity to get the essential resource to more children, to tackle this forgotten epidemic.

    Against this backdrop, Senegal offered fertile ground for improvement. Even before the pandemic, and in the midst of it, the country was interrogating its medical-oxygen infrastructure.

    “The government of Senegal established an ambitious scale-up strategy for oxygen as early as 2013,” wrote Lisa Smith, the access-to-medical-devices portfolio director for the market-dynamics program at the public-health nonprofit PATH, in an email to Undark. Then in 2017, she wrote, members of the Senegalese government attended a PATH-led meeting focused on widening oxygen access. There, the government highlighted its work with a private contractor to install and maintain pressure-swing adsorption, or PSA, plants—which produce purified oxygen from ambient air on-site—at a number of hospitals. After this event, Smith said, PATH started working with the government to offer additional support to close other gaps in Senegal’s oxygen-supply chain.

    A year into the pandemic, PATH published a report based on a nationwide survey of medical equipment, focused on oxygen infrastructure, noting where it was available and where it was most lacking.

    Key among the findings of the resulting report was that oxygen was heavily concentrated at emergency centers in large urban areas, but much scarcer at smaller health centers and posts that serve the majority of the population. For instance, of 29 COVID-treatment centers surveyed across 13 regions, Dakar, Senegal’s capital, had the highest concentration of key medical tools—62 percent of pulse oximeters, which estimate blood oxygen levels, and 84 percent of functional ventilators—despite the city making up less than a quarter of the country’s population.

    The equipment survey also revealed stark disparities in the distribution of PSA plants, which provide a reliable supply of oxygen. Nearly half of the treatment centers with access to a PSA plant, which cost upwards of $100,000 apiece, were concentrated in Dakar to meet the needs of the city’s dense population—such as the Ngor Health Center’s PSA plant, which was built there before COVID hit and became a boon during the pandemic.

    Within a large, sun-drenched courtyard on the hospital grounds, the PSA plant hums inside a locked concrete enclosure. As part of the setup, there is a black box called a compressor, which sucks in external air and pressurizes it. From there, the pressurized air is scrubbed as it runs through a filtration device to remove nitrogen and allow oxygen to pass through. The oxygen is then transferred to holding tanks, ready to be piped into the wards.

    In contrast, at most other health-care facilities where PSA plants are in short supply, health-care workers rely on smaller pieces of equipment such as oxygen concentrators and cylinders to supply the crucial gas. These come with their own challenges: Most concentrators, which are portable, suitcase-size machines, deliver oxygen at a rate that’s too slow for severe COVID patients, and cylinders can be refilled with new oxygen only at centralized plants, which means that supply can be disrupted because of unreliable transport.

    Maintaining this piecemeal infrastructure can also be impractical. At another health facility across town, this was evidenced by a pile of discarded concentrators strewn amongst other items—unused respirators in water-logged boxes, mosquito nets, and an old mat and metal bed frame stripped bare—stacked under a zinc roof just outside the entry ramp for emergency patients.

    Read: Think 168,000 ventilators is too few? Try three.

    Such infrastructural challenges aren’t unique to Senegal. A 2021 WHO technical consultation revealed that before the pandemic, the majority of low- and middle-income countries struggled to obtain medical oxygen. In sub-Saharan countries, 31 percent of facilities had interrupted access, while 25 percent had none at all.

    These wider findings on oxygen and COVID also helped inform child-pneumonia initiatives, including a clinical trial designed to test the value of pulse oximeters in these patients. The trial, part of a project called Tools for Integrated Management of Childhood Illness, or TIMCI—jointly run by PATH, Unitaid, and the Swiss Tropical and Public Health Institute—launched in August 2021 in multiple facilities in three countries, including the arid baobab-studded region of Thiès, an hour’s drive into the countryside beyond Dakar. Here, TIMCI supplied pulse oximeters to doctors at 59 health posts to diagnose incoming patients. As of September 2022, TIMCI has screened almost 17,000 sick children in Thiès.

    The devices work by attaching to a patient’s finger and painlessly measuring the level of oxygen in their blood. It’s a quick and inexpensive way of detecting a condition in which oxygen saturation levels dip dangerously below 90 percent, called hypoxemia. Hypoxemia increases the risk of death by pneumonia up to five times.

    The Senegalese trial—part of a larger multicountry initiative also involving Kenya, Tanzania, India, and Myanmar—intends to evaluate the effectiveness of pulse oximeters in more accurately and swiftly diagnosing hypoxemia, in order to then help children get the urgent oxygen treatment that they need and save lives. But such initiatives will only ultimately be effective if the essential oxygen supplies are on hand nearby.

    On a tree-lined street in downtown Dakar, Ndèye Astou Badiane sits inside the PATH regional headquarters contemplating the pandemic’s legacy. In Senegal, although the health system struggled with a real “increase in demand [for] oxygen,” says Badiane, who is a respiratory-care coordinator at the nonprofit, some good came out of it. The clear and urgent need, she adds, injected new momentum into national efforts to tackle oxygen shortages.

    For instance, the government, together with PATH, is now finalizing another assessment of its oxygen infrastructure, maintenance, and long-term sustainability. The overarching aim is “to improve oxygen availability and utilization in each health facility,” Badiane wrote in a follow-up email.

    This evolving assessment laid the foundation for the government’s most significant move: the plan to roll out dozens of new PSA plants, the units that produce oxygen on-site at hospitals, says Amad Diouf, the director of the Department of Infrastructure, Equipment, and Maintenance at Senegal’s Ministry of Health and Social Action. These crucial new oxygen plants, five of which are funded by UNICEF, are due to be installed by the end of 2022, with a focus on health centers across the country. At the start of the pandemic, with support from PATH and Unitaid, Senegal was able to acquire 175 oxygen concentrators, 1,000 oxygen masks, and 250 pulse oximeters.

    There are early indications that the effort to strengthen Senegal’s oxygen gaps is translating into gains in the fight against childhood pneumonia. A 2021 review study found that bolstering oxygen infrastructure in lower- and middle-income countries could cut child-pneumonia deaths in hospitals by almost half. And in Senegal, the pediatrician Mbodji says there has been a notable increase in the availability of oxygen at health facilities. Though it’s difficult to attribute solely to this change, Mbodji says, pneumonia deaths in children have declined over the past two years.

    The pandemic has also given pneumonia initiatives like TIMCI special resonance. COVID-19 was “an opportunity” for the Ministry of Health to recognize the importance of oxygen infrastructure and accelerate the spread of lifesaving tools like pulse oximeters through more health facilities, says Maymouna Ba, who leads the TIMCI project in Senegal.

    “Before TIMCI, before COVID-19, such equipment, such tools, were just available at higher levels like in hospitals, in health centers. But not in health posts where providers also need these kind of equipment, these kind of tools to better detect severe illness in the early stage,” Ba says. With the TIMCI trial ongoing, she adds, there are plans to eventually provide even more pulse oximeters to health posts across the whole country.

    Other pneumonia interventions have received a similar boost in recognition—such as the SPRINT project, or Scaling Pneumonia Response InnovaTions, a program run by UNICEF to expand access to antibiotics and oxygen treatment for pneumonia. The program was originally confined to certain regions, but since the pandemic began, Mbodji says, the government has been working on plans to extend it to the entire country.

    Senegal’s oxygen response is emblematic of changes unfolding elsewhere. COVID made plain that “you can’t wait for disaster to happen for the equipment to be here,” says Fatima Diaban, a critical-care physician and member of the Every Breath Counts Coalition, an initiative by the nonprofit JustActions focused on supporting national governments in reducing pneumonia deaths by the end of the decade. In May 2021, Senegal was among nine African nations to begin receiving help from PATH and the Clinton Health Access Initiative to procure new oxygen equipment, funded by $20 million from Unitaid. The Global Fund, an international health-care-focused funding organization, with support from government and private-sector donors, also provided $475 million to 66 lower- and middle-income countries for a similar purpose.

    Read: One of long COVID’s worst symptoms is also its most misunderstood

    Now that the pandemic has eased, some of these resources can be redeployed to treat childhood pneumonia—something that’s already under way in other countries such as Ethiopia, where the government announced plans in 2021 to redistribute the pulse oximeters and oxygen therapies it used for COVID elsewhere in its health-care system.

    Large aid donations often come with questions about whether such funding reaches the intended recipients in its entirety. PATH’s Smith said there are safeguards in place to ensure it does. “Each donor has unique requirements for accountability and responsible use of funds,” she wrote in an email. For instance, her organization worked closely with Senegal’s Ministry of Health and the Department of Infrastructure, Equipment, and Maintenance to distribute donated oxygen equipment to facilities in need.

    Overall, such initiatives could fast-track progress on pneumonia, a disease that’s still “very much neglected” in the global health discourse, despite its global burden, says Klugman of the Bill and Melinda Gates Foundation. Pneumonia is still chronically underfunded, taking just 5 percent of the money devoted to fighting infectious disease globally, and just 3 percent of the research funding allocated to infectious diseases from 2000 to 2017 by public and philanthropic funders in G20 countries.

    Prevention will be crucial—and progress is under way to develop new, targeted vaccines, which protect better against pneumonia compared with existing vaccines, Klugman says. But for now, oxygen remains a uniquely efficient way to save lives. As such, the pandemic responses that many countries have drawn up provide an ideal framework for action—a “foundation for continued declines in deaths from all-cause respiratory infections over the next decade,” according to a 2021 report on pneumonia and the coronavirus pandemic produced by JustActions.

    Indeed, it’s not just children with pneumonia who stand to benefit from this spread: Wider oxygen provisions will aid people with infectious diseases, cardiovascular diseases, and asthma.

    This larger importance, laid bare and elevated by the pandemic, is behind the recent September 2022 launch of the Lancet Global Health Commission on medical oxygen security, a new partnership of academics and NGOs, which will reportedly include strong representation from lower- and middle-income countries. The Commission seeks to build on the pandemic’s gains and provide policy makers with information and tools to close the crucial gaps in global oxygen-supply chains.

    Already, the benefits of expanded oxygen access are evident at the Ngor health center, where the copper pipes are reminders of a traumatic time but now stretch beyond the emergency room, ferrying oxygen to those who need it most. Just off the main corridor of the second floor, those pipes have been trained into a room with walls decorated with cheerful stickers of Dora the Explorer, flowers, and birds—a children’s ward.

    As Badiane puts it: “In 2022, really oxygen should be available and affordable in every health facility.”

    Sandy Ong

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