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Tag: Ziyad Al-Aly

  • How Much Less to Worry About Long COVID Now

    How Much Less to Worry About Long COVID Now

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

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

    Read: The future of long COVID

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

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

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

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

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

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

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

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

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

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

    Read: Long COVID is being erased—again

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

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

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

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

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

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    Katherine J. Wu

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  • Trying to Stop Long COVID Before It Even Starts

    Trying to Stop Long COVID Before It Even Starts

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

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

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

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

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

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

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

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

    Read: Inside the mind of an anti-Paxxer

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

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

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

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

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

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

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

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

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

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    Katherine J. Wu

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  • Medium COVID Could Be the Most Dangerous COVID

    Medium COVID Could Be the Most Dangerous COVID

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    I am still afraid of catching COVID. As a young, healthy, bivalently boosted physician, I no longer worry that I’ll end up strapped to a ventilator, but it does seem plausible that even a mild case of the disease could shorten my life, or leave me with chronic fatigue, breathing trouble, and brain fog. Roughly one in 10 Americans appears to share my concern, including plenty of doctors. “We know many devastating symptoms can persist for months,” the physician Ezekiel Emanuel wrote this past May in The Washington Post. “Like everyone, I want this pandemic nightmare to be over. But I also desperately fear living a debilitated life of mental muddle or torpor.”

    Recently, I’ve begun to think that our worries might be better placed. As the pandemic drags on, data have emerged to clarify the dangers posed by COVID across the weeks, months, and years that follow an infection. Taken together, their implications are surprising. Some people’s lives are devastated by long COVID; they’re trapped with perplexing symptoms that seem to persist indefinitely. For the majority of vaccinated people, however, the worst complications will not surface in the early phase of disease, when you’re first feeling feverish and stuffy, nor can the gravest risks be said to be “long term.” Rather, they emerge during the middle phase of post-infection, a stretch that lasts for about 12 weeks after you get sick. This period of time is so menacing, in fact, that it really ought to have its own, familiar name: medium COVID.

    Just how much of a threat is medium COVID? The answer has been obscured, to some extent, by sloppy definitions. A lot of studies blend different, dire outcomes into a single giant bucket called “long COVID.” Illnesses arising in as few as four weeks, along with those that show up many months later, have been considered one and the same. The CDC, for instance, suggested in a study out last spring that one in five adults who get the virus will go on to suffer any of 26 medical complications, starting at least one month after infection, and extending up to one year. All of these are called “post-COVID conditions, or long COVID.” A series of influential analyses looking at U.S. veterans described an onslaught of new heart, kidney, and brain diseases (even among the vaccinated) across a similarly broad time span. The studies’ authors refer to these, grouped together, as “long COVID and its myriad complications.”

    But the risks described above might well be most significant in just the first few weeks post-infection, and fade away as time goes on. When scientists analyzed Sweden’s national health registry, for example, they found that the chance of developing pulmonary embolism—an often deadly clot in the lungs—was a startling 32 times higher in the first month after testing positive for the virus; after that, it quickly diminished. The clots were only two times more common at 60 days after infection, and the effect was indistinguishable from baseline after three to four months. A post-infection risk of heart attack and stroke was also evident, and declined just as expeditiously. In July, U.K. epidemiologists corroborated the Swedish findings, showing that a heightened rate of cardiovascular disease among COVID patients could be detected up to 12 weeks after they got sick. Then the hazard went away.

    This is all to be expected, given that other respiratory infections are known to cause a temporary spike in patients’ risk of cardiovascular events. Post-viral blood clots, heart attacks, and strokes tend to blow through like a summer storm. A very recent paper in the journal Circulation, also based on U.K. data, did find that COVID’s effects are longer-lasting, with a heightened chance of such events that lasts for almost one full year. But even in that study, the authors see the risk fall off most dramatically across the first two weeks. I’ve now read dozens of similar analyses, using data from many countries, that agree on this basic point: The greatest dangers lie in the weeks, not months, after a COVID infection.

    Read: Long COVID could be a ‘mass deterioration event’

    Yet many have inferred that COVID’s dangers have no end. “What’s particularly alarming is that these are really life-long conditions,” Ziyad Al-Aly, the lead researcher on the veterans studies, told the Financial Times in August. A Cleveland Clinic cardiologist has suggested that catching SARS-CoV-2 might even become a greater contributor to cardiovascular disease than being a chronic smoker or having obesity. But if experts who hold this assumption are correct—and the mortal hazards of COVID really do persist for a lifetime (or even many months)—then it’s not yet visible at the health-system level. By the end of the Omicron surge last winter, one in four Americans—about 84 million people—had been newly infected with the coronavirus. This was on top of 103 million pre-Omicron infections. Yet six months after the surge ended, the number of adult emergency-room visits, outpatient appointments, and hospital admissions across the country were all slightly lower than they were at the same time in 2021, according to an industry report released last month. In fact, emergency-room visits and hospital admissions in 2021 and 2022 were lower than they’d been before the pandemic. In other words, a rising tide of long-COVID-related medical conditions, affecting nearly every organ system, is nowhere to be found.

    If mild infections did routinely lead to fatal consequences at a delay of months or years, then we should see it in our death rates, too. The number of excess deaths in the U.S.—meaning those that have occured beyond historic norms—should still be going up, long after case rates fall. Yet excess deaths in the U.S. dropped to zero this past April, about two months after the end of the winter surge, and they have stayed relatively low ever since. Here, as around the world, overall mortality rates follow acute-infection rates, but only for a little while. A second wave of deaths—a long-COVID wave—never seems to break.

    Even the most familiar maladies of “long COVID”—severe fatigue, cognitive difficulties, and breathing trouble—tend to be at their worst during the medium post-infection phase. An early analysis of symptom-tracking data from the U.K., the U.S., and Sweden found that the proportion of those experiencing COVID’s aftereffects decreased by 83 percent four to 12 weeks after illness started. The U.K. government also reported much higher rates of medium COVID, relative to long COVID: In its survey, 11 percent of people who caught the virus experienced lingering issues such as weakness, muscle aches, and loss of smell, but that rate had dropped to 3 percent by 12 weeks post-infection. The U.K. saw a slight decline in the number of people reporting such issues throughout the spring and summer; and a recent U.S. government survey found that about half of Americans who had experienced any COVID symptoms for three months or longer had already recovered.

    This slow, steady resolution of symptoms fits with what we know about other post-infection syndromes. A survey of adolescents recovering from mononucleosis, which is caused by Epstein-Barr virus, found that 13 percent of subjects met criteria for chronic fatigue syndrome at six months, but that rate was nearly halved at one year, and nearly halved again at two. An examination of chronic fatigue after three different infections—EBV, Q fever, and Ross River virus—identified a similar pattern: frequent post-infection symptoms, which gradually decreased over months.

    Read: It’s not just long COVID

    The pervasiveness of medium COVID does nothing to negate the reality of long COVID—a calamitous condition that can shatter people’s lives. Many long-haulers experience unremitting symptoms, and their cases can evolve into complex chronic syndromes like ME/CFS or dysautonomia. As a result, they may require specialized medical care, permanent work accommodations, and ongoing financial support. Recognizing the small chance of such tragic outcomes could well be enough to make some people try to avoid infection or reinfection with SARS-CoV-2 at all costs.

    But if you’re like me, and trying to calibrate your behaviors to meet some personally acceptable level of COVID risk, then it helps to keep in mind the difference between the virus’s medium- and long-term complications. Medium COVID may be time-limited, but it is far from rare—and not always mild. It can mean a month or two of profound fatigue, crushing headaches, and vexing chest pain. It can lead to life-threatening medical complications. It needs recognition, research, and new treatments. For millions of people, medium COVID is as bad as it gets.

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    Benjamin Mazer

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