Coronavirus Updates July 2024

[missy]

Long Covid Research Roundup ​

What have we learned in the first half of 2024?​

KATELYN JETELINA JUL 9

"

A lot of scientific questions remain about long Covid (LC). I will try to give a biannual update on the progress in our understanding, ongoing research, and what it means for you. Millions of Americans are dramatically impacted by this disease, and LC is also where most concerns lie for a majority of us when encountering Covid-19.

Here’s what we’ve learned over the past 6 months.

Note: This post builds on previous YLE posts about long Covid. If you missed those, search for “long Covid” in the YLE archive.

We finally have a definition​

What we knew: The number of people who get LC after infection has ranged dramatically from 2% to 75%. Reasons for this include differing definitions—for example, some define LC as persistent symptoms 4 weeks after infection, while some use 3 months, and others 6 months.

New info: The National Academies of Sciences established a definition:

Long COVID is an infection-associated chronic condition (IACC) that occurs after SARS-CoV-2 infection and is present for at least 3 months. It can manifest as a continuous, relapsing and remitting, or progressive disease state that affects one or more organ systems.

Why does it matter? This will greatly enhance the identification and treatment of LC because all researchers working on it will measure the same thing. About time!

We still don’t know how many people have LC, though​

What we knew: The general public is rightfully curious about the risk of LC after infection. Scientists hypothesize it’s decreasing (thanks to immunity). Unfortunately, data is limited. The U.S. Census publishes LC estimates over time to watch trends.

New info: The number of people experiencing LC has decreased slightly since 2022 but since stabilized. (Unfortunately, UK data stopped in March 2023.) This would suggest that risk has decreased, but immunity protection may hit a threshold.

​

The problem is this survey is imperfect. We can’t look at that y-axis and say, “6% of people get LC after infection.” The risk is likely smaller. This survey doesn’t have a comparison group, so people can have symptoms similar to LC, like fatigue, but caused by something else. This survey also has a 6% response rate (6 out of 100 people asked to take it took it), which biases the numbers.

Why does it matter? LC remains a risk of Covid-19 infection. How big of a risk? We aren’t sure, but likely smaller than 6%. Is that risk decreasing? We think so, but don’t have good visibility.

A huge piece of causal evidence in mice​

What we knew: LC is likely developed in several different ways (see figure below). One hypothesized pathway is autoimmunity—after infection, some antibodies called autoantibodies turn and attack the body’s cells and tissues. But, we’ve only had correlational studies—people with high autoantibodies also had higher rates of LC.

​

(Annotated by YLE)
New info: Two new mouse studies have shown a causal link between autoimmunity and LC. Scientists transferred autoantibodies (antibodies that incorrectly attack human cells) from LC patients to mice. The autoantibodies were detected in various tissues of the mice, including the heart, skeletal muscles, spinal cords, and neurons. Also, mice replicated neurological symptoms, muscle weakness, balance, and coordination issues after the transfer.

Why does it matter? Causal evidence slingshots our understanding of the role of autoimmunity for at least a subset of LC patients, paving the way for treatments like immunotherapies.

Clues on brain fog ​

What we knew: Multiple studies have shown that a SARS-CoV-2 infection disrupts the blood-brain barrier (BBB), allowing substances from the blood to enter the brain. This isn’t too surprising, as many viruses can do this. However, LC patients with brain fog have more of these substances in the brain.

New info: A new study examined brain circulation among a subset of LC patients and compared it to non-LC patients. LC patients who reported brain fog had more areas in their brains where blood vessels were “leaking.” They also had more blood clotting. (Interestingly, both LC and non-LC patients in the study showed reduced brain matter volume compared to uninfected patients, indicating these changes do not primarily cause fatigue and cognitive impairment.)

Why does it matter? Therapy targets related to BBB could potentially help LC patients with brain fog, paving another pathway for treatment.

Vaccination reduces LC even if vaccinated after infection​

What we knew: Several studies have shown that unvaccinated people are at higher risk of developing LC compared to vaccinated people. However, the degree of protection vaccines provide varies significantly across these studies.

New info: A new systematic review of more than 600,000 people found vaccines before and after infection reduce risks of LC:

• Vaccination before infection: 10 (out of 12) studies showed that vaccination reduced LC. But you need to keep up with vaccinations—one dose didn’t seem to help much.
• After infection and/or LC symptoms: Five (out of five) studies showed that vaccines prevented and helped reduce LC symptoms.

Why does it matter? Stay up to date on your vaccines to reduce LC risk.

Another study shooting down Paxlovid​

What we knew: Evidence on Paxlovid’s ability to reduce LC has been mixed. This may be due to studies being limited to a short course of the medication (5 days).

New info: LC patients were randomized to receive a 15-day course of Paxlovid or a placebo. After 10 weeks of the trial, there was no statistical difference in LC symptoms.

Why does it matter? Unfortunately, this adds to the evidence that Paxlovid is ineffective against LC. It may still work for LC symptoms caused by viral reservoirs (rather than, for example, autoimmunity), but overall, more resources should be invested into other targeted therapies.

Bottom line​

Our understanding of LC is slowly but surely growing. Immunity may be helping reduce the prevalence of LC, but it is imperfect protection, and we still have very few treatments for the millions suffering.




Big thanks to Nini Munoz, who helped “translate” several of these studies. She is a passionate science communicator and the author of TECHing it Apart.

“Your Local Epidemiologist (YLE)” is written by Dr. Katelyn Jetelina, MPH PhD
"

 

[missy]

"

Epidemiology of RSV: Accurate Diagnosis, Treatment Options, and Risk Factors​

Is it Flu, COVID, or RSV

Forest W. Arnold, DO, MSc: Hello. I'm Dr Forrest Arnold. Welcome to Season 2 of the Medscape InDiscussion podcast series on respiratory syncytial virus (RSV) in adults. Today we'll discuss epidemiology and the approach to RSV in adults. First, let me introduce my guest, Dr Angela Branche, associate professor of medicine at the University of Rochester. Part of her research involves population-based studies of RSV infection and the development of vaccine and antiviral agents for RSV. Dr Branche, welcome to the Medscape InDiscussion podcast.

Angela R. Branche, MD: Thank you, Dr Arnold. I am happy to be here.

Arnold: Please tell us where you work and what your job entails.



Branche: I work at the University of Rochester Medical Center. I'm an adult infectious disease physician. My clinical practice, both inpatient and outpatient, is anything related to infectious diseases or HIV medicine. I have been here about 12 years altogether. Rochester has a longer winter season, which makes it the ideal place to study respiratory viruses. Historically, the University of Rochester has been known for its study of respiratory viruses like influenza, RSV, human metapneumovirus, and coronaviruses. We've also done a lot of work defining the burden of disease in adults as well as helping to develop vaccines and therapeutics related to that.

Arnold: Do you think the cold weather and people having to be forced together is what promotes all those respiratory infections, including RSV, or is it another factor?

Branche: I think it's a lot of indoor exposure — folks hanging out together indoors and in environments where they can transmit viruses. We have 6 months of winter, so that's a lot of time for people to be indoors transmitting viruses to each other.

Arnold: Yes, it sure is. Since you're an epidemiologist, why don't you tell us some of the prevalence and impact of RSV infections on adults?


Branche: RSV infections cause seasonal epidemics in adults and children every year. In most seasons, the incidence is probably similar to influenza's, causing as many infections as influenza in adults, which I think is something that's not as well recognized. I would say the annual incidence of RSV causing hospitalizations in adults 60 years or older ranges probably somewhere between 6% and 8%. It causes between 140,000 and 170,000 hospitalizations every year, probably 1-2 million medically attended illnesses. Those are illnesses where you'll see your doctor, go to an urgent care, be seen in the emergency room, etc. Depending on the estimates you look at, there are about 10,000-15,000 deaths in older adults every year, which is not insignificant.

To put it in perspective with influenza, there are anywhere from 10,000 to, in a very bad flu season, up to 80,000 or 90,000 deaths due to influenza in all adults, not just older adults. RSV causes very predictable mortality of 10,000 to 14,000 or 15,000 deaths every year, and it doesn't change very much; that makes it quite significant in this population.

Arnold: If you look at the incidence of any respiratory virus, I think people are surprised to hear that we declare that there's an epidemic every year. But there is, and I think you're very correct in saying that. Pre-COVID and before RSV was very significant in adults, we used to just, in the middle of the epidemic, treat influenza based on clinical symptoms and not so much on a test after a while. How has that changed today with an epidemic? Is there a point at which we can stop testing, or now, with more viruses, is that test with the nasopharyngeal swab important?

Branche: Unfortunately, in the winter season we have multiple viruses and bacteria circulating that can cause respiratory illnesses that require you to see your doctor or be hospitalized — what we call medically attended illnesses. RSV tends to start circulating first, interestingly enough, in the Southeast, and then it moves its way up to the Northeast and starts to move to the Midwest. The last place where we see RSV epidemics starting to appear in communities is the Northwest. By December, probably the entire country will have lots of RSV circulating in their communities, but the timing is slightly different. Flu overlaps with that. Flu tends to appear about a month to 6 weeks after you start to see RSV. You'll see RSV first, and then you'll see flu appear in your community about 4-6 weeks later.


There are other viruses — coronaviruses, human metapneumoviruses — that also overlap in that same winter season. They might have slightly different timing. December or January might be when you start to see metapneumoviruses appearing and peaking. Coronaviruses are very variable. The clinical syndrome of any one of these illnesses in people at risk for severe disease, for bronchitis and pneumonia — specifically in older adults — overlaps as well. So it's really clinically indistinguishable to a treating physician or provider whether what's causing illness is flu vs COVID vs RSV. They all look the same. There are some minor differences; RSV tends to have less fever and tends to be a very wheezy kind of illness, but by and large, it's clinically indistinguishable. It's really fortunate that we now have good diagnostic testing, because you do need to make a diagnosis so your patient knows what they have, and so they also know what they don't have. Why is that important? There are antiviral treatments for influenza and COVID. So if you know that it's COVID or flu, you can give Tamiflu, you can give Paxlovid, and they will help decrease the duration of illness and the severity of symptoms. RSV does not have a treatment, but on the other hand, if someone has RSV, you don't want to give them a drug they don't need. Being able to prescribe the right treatment for the right infection is of critical importance. It also helps you manage your patient's expectations. If there's something I can do that'll help, great. If there's something I can do that won't help, I need my patient to know that too. These are all really important clinical decision-making tools, which is why we really do stress making that diagnosis whenever you can.


Arnold: We've talked on this podcast before about a 3-plex test for influenza, COVID, and RSV. There's also a multiplex that includes other viruses, such as adenovirus, parainfluenza, and metapneumovirus. What you just said was really important and I think it's worth repeating. Maybe you could just tell us the consequences of delayed or inaccurate diagnosis.


Branche: I'm a respiratory virologist and an infectious disease doctor. I find it so critical and important to be able to tell my patients what I think they have or what a diagnostic test shows. Obviously I'm a fan of using diagnostic tools whenever you can, but I recognize that in practice, some of these tests are expensive. They're not always widely available. Clinicians really have to think what's going to shift the needle in terms of how they care for their patients. I think that early and timely diagnosis of influenza and SARS-CoV-2 will help you make important treatment decisions. I think early and timely diagnosis of RSV will help you to know how to support your patients and will prevent you from doing things that aren't needed, like getting echocardiograms, getting urine tests, giving antibiotics, giving things that won't help your patient and potentially could actually hurt them. I think our early diagnosis, specifically of RSV, will help with transmission in important settings like hospitals, nursing homes, in adults who go to daycares. Even within a home, knowing that you have an RSV-infected person, because RSV is so easy to transmit, will help you protect others around that infected person.


Arnold: How does the epidemiology of RSV in adults differ from that in children?


Branche: Like most respiratory viruses, RSV does tend to cause more severe illness in extremes of age. The most infections we see in a year, nationwide or worldwide, are in children 2 years or under. It's a major cause of hospitalization in young children. However, the most deaths that we see in the United States are in older adults. That's why, even though you might not see millions of cases in adults in the United States, in the ones you do see, there's a significant risk for mortality that we don't have in young children right now — thankfully. The other thing that's different about these two groups in terms of their illnesses is that they can present differently. Often, young babies and toddlers that get infected with RSV will have bronchiolitis, which is sort of a childhood version of bronchitis — really severe airway obstruction. They could develop pneumonia. They tend to get acutely ill very quickly. Within a few days, they'll present to your office or the hospital because they're quite sick. Many of them will have fever, and so it's easy to see the impact of RSV early on with children. In adults it tends to be a little more insidious. They might have a cold for 3 or 4 days, and then as it progresses and gets down to the lower respiratory tract into the lungs and the lower airways, that's when they'll have wheezing and shortness of breath. If they have underlying chronic medical conditions affecting the heart or the lungs, they'll have exacerbations of those conditions. By time they come to see you, they're probably 5-7 days into their illness. At that point, it's not necessarily how quickly they can clear the virus; it's more about what damage has this viral infection done to their airways and their lungs? What has it exacerbated? How do you manage all those other things?


Arnold: RSV in both of those populations, children and adults, peaks in the winter. But do the peaks exactly overlap?


Branche: I think it starts in children first, typically. You'll start to see babies being hospitalized or seeing their doctors probably about 2-3 weeks before you start to see adult infections. The peak for babies will tend to be a few weeks earlier than adults, but there is pretty good overlap. For whatever reason, babies and children, and school-age children particularly, are just sort of the reservoirs for RSV and what starts an epidemic within the community.


Arnold: Adults should take the increase in RSV in children as a heads-up that, hey, they really need to be cautious about the weeks ahead because they'll be more at risk. What risk factors are we concerned about that might lead to the worst RSV, that results in a hospitalization for adults?


Branche: We've been studying this here, and others around the country and around the world have been studying it too. There are some very specific risk factors that predispose people to more severe RSV disease. They're not unique to RSV. You'll see some of the similar risk factors with influenza and COVID as well. The most well-defined risk factor in adult populations is age. For every decade of life over 60, you basically double the incidence of RSV as you move from sixties to seventies and seventies to eighties. Adults in their mid-seventies and eighties are probably the best-defined and potentially the highest-risk groups. We tend to recommend universal vaccination in those age groups.


For adults in their fifties and sixties, risk is more based on the presence of certain underlying medical conditions; specifically, chronic cardiac and chronic pulmonary conditions confer some of the higher risks. Chronic pulmonary conditions like COPD and asthma have been associated with increased risk for hospitalization, needing oxygen, and ending up in the ICU. Risks that I think are less well appreciated, but may be even more important, are the cardiac risks. RSV has been associated with increased risk of having an acute myocardial infarction; after you have an RSV infection, in those first 3 days there's maybe as high as three times the risk of having a heart attack in somebody with heart disease. It's also associated with up to a 20 times increased risk for hospitalization if you have heart failure and you get RSV. That's an incredible risk factor. There are other things that we're still working to understand and define, like diabetes — but mostly poorly controlled diabetes — chronic kidney disease, folks on dialysis, and those sorts of things.


Arnold: When we consider epidemiology specifically, people are more familiar with the communicability of a pathogen as expressed as R naught (R0). Would you remind us about what R0 means and where RSV falls on that scale?


Branche: R0 is a mathematical model that helps you to understand how transmissible a virus is from person to person within a community. To put that in perspective, measles is probably the most transmissible virus that's ever affected human populations, and I think that had an R0 of something like 10-12, which means that for every person that gets a measles infection, they would then go on to transmit it to 10-12 people. Seasonal influenza has an R0 of somewhere around 1.5, so between 1 and 2. Every person infected with flu will go on to potentially infect one or two other individuals, if they expose them to their infection. SARS-CoV-2 (COVID) has an R0 of somewhere between 2 and 3. So that's more than flu but not as infectious as RSV, whose R0 is 3. Every person infected with RSV will go on to infect three other individuals. That's probably because RSV can infect you in a way that many other respiratory viruses can't, including influenza and to some extent SARS-CoV-2. With RSV, you don't get infected just by having somebody sneeze or cough in the air and inhaling those respiratory droplets. With RSV, it's actually in the snotty nose from the kid that you're holding or whose nose you're wiping. It's on the surface that the tissue landed on, and it stays on that surface for a number of hours. That's something that influenza can't do. It can't live on surfaces for an extended period of time, whereas RSV is more hardy and it can. So there's the possibility of transmission by just coming into contact with contaminated surfaces, which is what probably increases that R0 a little bit.


Arnold: When we think about RSV and epidemics from the healthcare worker perspective, they encounter hospital protocols where they work, they encounter state policies in the state they live in, and then there are national CDC guidelines. What do you recommend to these healthcare workers to process all of these different suggestions coming at them?


Branche: I think navigating all of that is tricky. I would pick two of the three recommendations and not try to synthesize all three. The most important guidance is what's happening locally. Whatever your local state health department or local health department or local institution advises, that's probably the first one you should try. They are a little bit different, but they're not so different that it'll really have a meaningful impact on transmission. I would start first with whatever your local institution's guidance is. I think the CDC is a great resource. That would be my next approach, to just get a general overview of why policies are what they are. I think the CDC offers the best overview and explanation of why we do certain isolation practices — contact vs droplets vs a combination of both, which is what we typically do with RSV. I think the CDC also has a lot of good resources for healthcare workers around vaccinations and risk factors, and how to have conversations about vaccinations with your patients. That would probably be my second look if I were a healthcare worker and I was confused about all the different recommendations and how they do and don't overlap.


Arnold: Right. The local guidelines may have more specific recommendations for the isolation you're talking about or cohorting. I'm interested in your opinion on cohorting; what do you think its role is?


Branche: Cohorting is a tool that we use to prevent nosocomial transmissions within hospitals and also within long term care facilities. I think it's very important. Nursing homes are a good example of how cohorting does or doesn't work, or may or may not be important. When you have a nursing home that does routine testing of respiratory illnesses, for influenza and RSV, and they detect RSV, then they can isolate the entire floor. They can start by isolating the room and then the entire floor. They can do screening testing of that floor to see if there's asymptomatic transmission going on. That's how cohorting really helps you to contain the spread of the virus within your healthcare system or your institution or your ward. In the absence of cohorting, of knowing when somebody is asymptomatically transmitting virus — or potentially their risk of becoming infected because they're near somebody who's infected — I think what you end up having is a rapid spread of transmission of the virus throughout that area, throughout the nursing home, throughout the unit. Cohorting is one of our best tools for prevention. When you have folks confined to certain locations and you know that people will be bringing in viruses, how do you prevent that transmission? I think cohorting is one of our strategies.


Arnold: As we wrap up today, is there a certain website or place you can recommend to healthcare professionals who seek to learn more about RSV diagnosis and management?


Branche: I really do like to direct people to the CDC. I think the tools there are exceptional. They have tools for healthcare workers and they have tools for patients. I would really strongly recommend that folks visit those sites and make use of those resources for all the questions that they have on everything from disease burden, to transmission, to surveillance testing, to vaccines, and to treatments. All of those questions are answered in a very detailed way that I think will be helpful.


Arnold: Thank you. Today we've heard how important an accurate diagnosis is so that treatment can be directed accordingly, and so that treatment for COVID or influenza cannot be used on somebody who doesn't have that respiratory virus. Another important point was that for each decade of life over 60, the incidence of RSV in patients doubles, and heart disease increases the risk for hospitalization up to 20 times. Today we've talked to Dr Branche about epidemiology and the approach to RSV in adults. Thank you for tuning in. Please take a moment to download the Medscape app to listen and subscribe to this podcast series on RSV and adults. This is Dr Arnold for the Medscape InDiscussion podcast.

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[missy]

"

The Hardest I've Cried​

— Notes from a physician fighting helplessness and misinformation​

by Joseph S. Thomas, MD July 12, 2024

Thomas is a hospitalist in New York State.
On November 28, 2021, scrolling through Twitter (now X, I suppose), I came across a tweet by @SailingKateMDopens in a new tab or window:
"Checked my ICU list after being gone for a few days for the holiday ... Every single one of my COVID patients died while I was gone. All of them."
Reading that hit me like a truck. That evening, I was 6 years out of medical school and in my third year as an attending hospitalist physician. Just the year prior, as the first waves of the pandemic raged, I had felt so helpless as my team experienced more patient deaths than we ever had before, despite herculean efforts. In that instant, I heard the voices of families saying goodbye to their loved ones over the phone and could almost feel the deep impressions on my face left by my N95. Then the moment passed and, as I usually do, I packed it away in a mental compartment reserved for emotional things and went on with my day.

Well, almost.
As I walked into my kitchen, tweet still glowing on my phone, it felt like all the thoughts and helpless feelings filed away in that compartment came spilling out, like my mental lid was no longer holding fast. It rattled me, so I sought refuge from the deluge in my favorite mindless activity: I threw on some headphones, put on a podcast, and started doing the dishes, hoping the soapy water would help me dodge the mental tsunami.
It almost worked. The helplessness roared back moments later and every effort I made to drown it out failed. I quietly put the sponge down and removed my headphones. My knees felt wobbly. I gingerly walked to the living room, where my wife sat on the couch working. I barely heard her phone ring with her father's usual nightly call. With that painful tweet in mind, I only heard myself saying, "I don't think I'm okay. I don't think I'm going to be okay for a long time."

What happened next might have been comical if I had been watching from outside. I would have watched my wife blanch as her husband, who rarely cries, suddenly collapsed in tears. I would have seen her frantically (but politely) hang up on her father and scramble across the couch to take my sobbing, shuddering body in her arms. As we huddled together, I felt it all. Every dying patient, every piece of disinformation I saw on social media, and every pro-mitigation argument I had to make suddenly burst forth from me in desperate, pathetic moans. I had not cried that hard in over a decade. My tears subsided after a few minutes and we exhaustedly went to bed. But I still wasn't okay.
A recent studyopens in a new tab or window by G. Camelia Adams and team looked at physicians who were involved in the initial peak of the pandemic and identified five major categories of coping strategies (both positive and negative). Among other conclusions, the researchers determined that "Despite efforts to employ adaptive coping, physicians' rates of psychological and physical health difficulties remained high or worsened over 1 year."

The study reminded me I was not alone: other physicians' mental health had suffered due to feelings of helplessness. When things ramped up in 2020, I, like other physicians at COVID-19 centers, became an expert in diagnosis and treatment of the disease (or as much as possible with such limited and rapidly changing information). Beyond the hospital, I started blogging regularly and increased social media posting to provide education to my little corner of the internet. As I often tell people, "It was either that or cry in a corner" (actual incident of crying in a corner notwithstanding).
I have looked beyond myself and my personal "resilience." If you work in healthcare and are like me, you probably hate that word. We saw the world go from nightly applause to hurling insults and accusations of "pharma shill." When we finally figured out what reasonable protection and prevention looked like, it was undermined by lack of funding, poor institutional messaging, and a failure to employ actual public health principles as folks desperately tried to return to pre-2020 status quo. This all led to soaring feelings of helplessness among healthcare workers, which had a traumatizing mental health impactopens in a new tab or window for many.

The old "medicine is a calling" adage lost whatever shine it had left when members of our own profession began spreading COVID disinformation. Our calling instead should be advocating for positive change within and beyond the field. Some of our colleagues advocate at the policy level, meeting with legislators. Some run for local or state office. Some, like me, combat disinformation online. As physicians, part of work-life integration must include time for change. I used to be less declarative with that. At times, I barely maintained my own sanity, so how could I tell people to do anything more?
Yet, it is exactly that struggle that drove me to write this. Fact-check that erroneous post. Call out that bogus claim. Perhaps create: anything from a tweet or Instagram caption to a full editorialopens in a new tab or window or article. Get more good information out into the world.
It is not easy. Brandolini's Law says,opens in a new tab or window "The amount of energy needed to refute bullshit is an order of magnitude bigger than needed to produce it," and this axiom has never been truer than what I experience while countering disinformation. It is much easier to write a catchy, sensationalist headline that sparks outrage (despite paltry evidence) than to write nuanced scientific messaging with higher-quality evidence, especially amid the cacophony of mean-spirited replies. That imbalance is what those who spread disinformation count on.

There are many frustrating, non-patient care-related aspects of healthcare -- the things that make us say to ourselves, "Why can't I just take care of my patients?" Countering disinformation can seem like one of those frustrating things, and the sheer number of misleading claims on the internet can spark feelings of helplessness in and of itself. Still, while individual self-care is incredibly important, we must also strive for systemic change to allow better delivery of care to our patients. This can fight the helpless feeling. We need to lift each other's voices and use our ability to educate and empower patients on a much broader scale.
And maybe we can feel a little less helpless.
Joseph S. Thomas, MD,opens in a new tab or window is a hospitalist with Buffalo Medical Group. He is also a clinical instructor at the University at Buffalo Catholic Health System in the Internal Medicine Training Program, and a deputy editor of Digital Media for the Journal of Hospital Medicine.

"

 

[AprilBaby]

Thanks Missy! I came down with round 3 Covid at 4 am today. I’m hoping to get Paxlovid after 11:30 video call. I had a vaccine 2 weeks ago and I did get the RSV last year as we have a baby in the family. If I get more brain fog I won’t have a brain left!

 

[OboeGal]

Thanks Missy! I came down with round 3 Covid at 4 am today. I’m hoping to get Paxlovid after 11:30 video call. I had a vaccine 2 weeks ago and I did get the RSV last year as we have a baby in the family. If I get more brain fog I won’t have a brain left!

Oh, no - wishing you fast and thorough healing, and no aftereffects!

 

[missy]

Thanks Missy! I came down with round 3 Covid at 4 am today. I’m hoping to get Paxlovid after 11:30 video call. I had a vaccine 2 weeks ago and I did get the RSV last year as we have a baby in the family. If I get more brain fog I won’t have a brain left!

Ugh, I am sorry Aprilbaby! I hope you have a fast and easy recovery. Sending bucketloads of healing vibes!

 

[missy]

"

Biden Is Positive for COVID-19​

— Biden will fly to his home in Delaware and "self-isolate"​

by Associated Press July 17, 2024

(AP Photo/Susan Walsh)
President Joe Biden tested positive for COVID-19 while traveling Wednesday in Las Vegas and is experiencing "mild symptoms," including "general malaise" from the infection, the White House said.
Press secretary Karine Jean-Pierre said Biden will fly to his home in Delaware, where he will "self-isolate and will continue to carry out all of his duties fully during that time." The news had first been shared by UnidosUS president and CEO Janet Murguía, who told guests at the group's convention in Las Vegas that the president had sent his regrets and could not appear because he tested positive for the virus.

Kevin O'Connor, DO, the president's physician, said in a note that Biden "presented this afternoon with upper respiratory symptoms, to include rhinorrhea (runny nose) and non-productive cough, with general malaise." After the positive COVID-19 test, Biden was prescribed the antiviral drug nirmatrelvir-ritonavir (Paxlovid) and has taken his first dose, O'Connor said.
Biden was slated to speak at the Unidos event in Las Vegas Wednesday afternoon as part of an effort to rally Hispanic voters ahead of the November election. Instead, he departed for the airport to fly to Delaware, where he had already been planning to spend a long weekend at his home in Rehoboth Beach.
Biden gingerly boarded Air Force One and told reporters traveling with him, "I feel good." The president was not wearing a mask as he walked onto Air Force One.
The president had previously been at the Original Lindo Michoacan restaurant in Las Vegas, where he was greeting diners and sat for an interview with Univision.

"

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[missy]

"​

​

Paxlovid After a COVID Exposure Fails to Reduce Household Transmission​

— Nearly all trial participants had some level of immunity at baseline, however​

by Katherine Kahn, Staff Writer, MedPage TodayJuly 17, 2024

Nirmatrelvir-ritonavir (Paxlovid) did not prevent people exposed to COVID-infected household members from getting infected with the virus, according to the final results of the phase II/III EPIC-PEP study.
Across more than 2,700 exposed adults in the trial, symptomatic confirmed infections at 14 days occurred in 2.6% of those taking a 5-day course of the antiviral medication, 2.4% of those receiving a 10-day course, and 3.9% of the placebo recipients. Neither of those differences versus the placebo group were statistically significant (P=0.17 and P=0.12, respectively), reported Jennifer Hammond, PhD, head of antiviral development at Pfizer in Collegeville, Pennsylvania, and colleagues.

Asymptomatic infections developed in about 2% of participants in the 5- and 10-day nirmatrelvir-ritonavir groups versus 3.1% of the placebo group, but again the differences were not statistically significant, the researchers detailed in the New England Journal of Medicineopens in a new tab or window.
"The secondary attack rate among household contacts of individuals infected with the Omicron variant is estimated to be up to 81%," Hammond and researchers wrote in the study's supplementary material. "Currently, postexposure prophylactic treatment for house contacts of SARS-CoV-2-infected individuals is not available, although such an approach is recommended in other infectious disease settings."
Currently, nirmatrelvir-ritonavir is FDA approvedopens in a new tab or window only as a 5-day regimen for treating adult outpatients with mild-to-moderate COVID-19 who are at risk for severe disease.
Hammond's team determined that the incidence for the development of symptomatic COVID-19 by day 14 among participants at high risk for severe disease did not differ significantly between the groups. And, in a subgroup analysis, no difference was noted in outcomes during periods when the Delta or Omicron variant predominated.

The study's final results come on the heels of the EPIC-SRopens in a new tab or window trial, which found that nirmatrelvir-ritonavir failed to shorten illness duration as a treatment for COVID-19 in standard-risk and vaccinated at-risk patients. However, a subgroup analysis of that study found that the antiviral is still likely to keep higher-risk patients from developing severe disease. The earlier EPIC-HRopens in a new tab or window trial found that unvaccinated, high-risk patients were significantly less likely to die or be hospitalized if they took nirmatrelvir-ritonavir, which supported the drug's 2023 approval.
In the EPIC-PEP trial, 91% of participants were seropositive for SARS-CoV-2 at baseline, most likely a result of previous infection or vaccination, Hammond and authors noted. "It is not known whether the high baseline seropositivity rates observed in this trial led to the lower-than-expected rates of household transmission," they wrote. About 13% in all three groups had received one or more doses of a COVID-19 vaccine.

Among participants seropositive at baseline, confirmed COVID-19 developed by day 14 in 2.2% and 2.0% in the 5- and 10-day nirmatrelvir-ritonavir groups and 3.6% in the placebo group. The between-group differences were not statistically significant.
Viral loads decreased over time among participants with a positive SARS-CoV-2 test across all groups. One participant each (2.6% and 2.1%) in the 5- and 10-day prophylaxis groups experienced a rebound in viral load. None of those in the placebo group had a viral load rebound.
The most common treatment-related adverse event in the nirmatrelvir-ritonavir prophylaxis groups was mild-to-moderate alterations in taste or metallic taste. Nausea and diarrhea occurred in at least 1% of prophylaxis recipients, with most events being mild.
Of note, the 10-day regimen had a similar safety profile to the shorter regimen. This may be important because in regards to treatment of confirmed COVID-19 with nirmatrelvir-ritonavir, "longer treatment durations are being explored in some patient populations," the authors wrote.

The trial took place from September 2021 to April 2022. Researchers randomized 921 participants to the 5-day nirmatrelvir-ritonavir group, 917 to the 10-day group, and 898 to the placebo group. About 21% underwent randomization before Dec. 20, 2021. Median age was 43 years, and 47% were men. Over 70% of participants had coexisting medical conditions putting them at risk for severe COVID-19. Adherence to assigned regimens was about 95% across the three trial groups.
COVID-19 infection was confirmed by reverse-transcriptase-polymerase-chain-reaction (RT-PCR) or rapid antigen testing in all groups. All participants in the primary analysis of the study tested negative for COVID-19 on RT-PCR or rapid antigen testing at baseline.
Limitations of the study include limited effectiveness of the blinding due to the distinctive taste of nirmatrelvir-ritonavir, the lack of detailed data on index patients since they are not direct participants in the trial and did not consent to provide information, and a potential effect from other infected household members.

• 
  
  Katherine Kahn is a staff writer at MedPage Today, covering the infectious diseases beat. She has been a medical writer for over 15 years.
• 
  
• "

 

[missy]

"
Medscape Internal Medicine > Medicine Matters
COMMENTARY

New Mid-Year Vaccine Recommendations From ACIP​

Sandra Adamson Fryhofer, MD


ACIP, the CDC's Advisory Committee on Immunization Practices, met for 3 days in June. New vaccines and new recommendations for respiratory syncytial virus (RSV), flu, COVID, and a new pneumococcal vaccine were revealed.


RSV Protection
We'll begin with RSV vaccines for adults aged 60 or older. For this group, shared clinical decision-making is out; it no longer applies. New, more specific recommendations from ACIP for RSV vaccines are both age based and risk based. The age-based recommendation applies to those aged 75 or older, who should receive a single RSV vaccine dose. If they have already received a dose under the old recommendation, they don't need another one, at least for now.

The risk-based recommendation applies to adults from age 60 up to 75, but only for those with risk factors for severe RSV. These risk factors include lung disease, heart disease, immunocompromise, diabetes, obesity with a BMI of 40 or more, neurologic conditions, neuromuscular conditions, chronic kidney disease, liver disorders, hematologic disorders, frailty, and living in a nursing home or other long-term care facility. Those aged 60-75 with these risk factors should receive the RSV vaccine, and those without them should not receive it. The best time to get the RSV vaccine is late summer, but early fall administration with other adult vaccines is allowed and is acceptable.

Vaccine safety concerns were top of mind as ACIP members began their deliberations. Possible safety concerns for RSV vaccines have been detected for Guillain-Barré syndrome, atrial fibrillation, and idiopathic thrombocytopenic purpura. Safety surveillance updates are still interim and inconclusive. These signals still need further study and clarification.

Two RSV vaccines have been on the market: one by Pfizer, called Abrysvo, which does not contain an adjuvant; and another one by GSK, called Arexvy, which does contain an adjuvant. With the recent FDA approval of Moderna's new mRNA RSV vaccine, mRESVIA, there are now three RSV vaccines licensed for those 60 or older. Arexvy is now FDA approved for adults in their 50s. That just happened in early June, but ACIP doesn't currently recommend it for this fiftysomething age group, even for those at high risk for severe RSV disease. This may change with greater clarification of potential vaccine safety concerns.

There is also news about protecting babies from RSV. RSV is the most common cause of hospitalization for infants in the United States, and most hospitalizations for RSV are in healthy, full-term infants. We now have two ways to protect babies: a dose of RSV vaccine given to mom, or a dose of the long-acting monoclonal antibody nirsevimab given to the baby. ACIP clarified that those who received a dose of maternal RSV vaccine during a previous pregnancy are not recommended to receive additional doses during future pregnancies, but infants born to those who were vaccinated for RSV during a prior pregnancy can receive nirsevimab, which is recommended for infants up to 8 months of age during their first RSV season, and for high-risk infants and toddlers aged 8-19 months during their second RSV season.

Last RSV season, supplies of nirsevimab were limited and doses had to be prioritized. No supply problems are anticipated for the upcoming season. A study published in March showed that nirsevimab was 90% effective at preventing RSV-associated hospitalization for infants in their first RSV season.


COVID
Here's what's new for COVID vaccines. A new-formula COVID vaccine will be ready for fall. ACIP voted unanimously to recommend a dose of the updated 2024-2025 COVID vaccine for everyone aged 6 months or older. This is a universal recommendation, just like the one we have for flu. But understand that even though COVID has waned, it's still more deadly than flu. Most Americans now have some immunity against COVID, but this immunity wanes with time, and it also wanes as the virus keeps changing. These updated vaccines provide an incremental boost to our immunity for the new formula for fall. FDA has directed manufacturers to use a monovalent JN.1 lineage formula, with a preference for the KP.2 strain.

Older adults (aged 75 or older) and children under 6 months old are hit hardest by COVID. The littlest ones are too young to be vaccinated, but they can get protection from maternal vaccination. The uptake for last year's COVID vaccine has been disappointing. Only 22.5% of adults and 14% of children received a dose of the updated shot. Focus-group discussions highlight the importance of a physician recommendation. Adults and children who receive a healthcare provider's recommendation to get the COVID vaccine are more likely to get vaccinated.

Pneumococcal Vaccines
On June 17, 2024, a new pneumococcal vaccine, PCV21, was FDA approved for those aged 18 or older under an accelerated-approval pathway. ACIP voted to keep it simple and recommends PCV21 as an option for adults aged 19 or older who currently have an indication to receive a dose of PCV. This new PCV21 vaccine is indicated for prevention of both invasive pneumococcal disease (IPD) and pneumococcal pneumonia. Its brand name is Capvaxive and it's made by Merck. IPD includes bacteremia, pneumonia, pneumococcal bacteremia, and meningitis.

There are two basic types of pneumococcal vaccines: polysaccharide vaccines (PPSV), which do not produce memory B cells; and PCV conjugate vaccines, which do trigger memory B-cell production and therefore induce greater long-term immunity. PCV21 covers 11 unique serotypes not in PCV20. This is important because many cases of adult disease are caused by subtypes not covered by other FDA-approved pneumococcal vaccines. PCV21 has greater coverage of the serotypes that cause invasive disease in adults as compared with PCV20. PCV20 covers up to 58% of those strains, while PCV21 covers up to 84% of strains responsible for invasive disease in adults. But there's one serotype missing in PCV21, which may limit the groups who receive it. PCV21 does not cover serotype 4, a major cause of IPD in certain populations. Adults experiencing homelessness are 100-300 times more likely to develop IPD due to serotype 4. So are adults in Alaska, especially Alaska Natives. They have an 88-fold increase in serotype 4 invasive disease. Serotype 4 is covered by other pneumococcal vaccines, so for these patients, PCV20 is likely a better high-valent conjugate vaccine option than PCV21.

Flu Vaccines
What's new for flu? Everyone aged 6 months or older needs a seasonal flu vaccination every year. That's not new, but there are two new things coming this fall: (1)The seasonal flu vaccine is going trivalent. FDA has removed the Yamagata flu B strain because it no longer appears to be circulating. (2) ACIP made a special off-label recommendation to boost flu protection for solid organ transplant recipients age 18 through 64 who are on immunosuppressive medications. These high-risk patients now have the off-label option of receiving one of the higher-dose flu vaccines, including high-dose and adjuvanted flu vaccines, which are FDA approved only for those 65 or older.

"

 

[missy]

"

A Summer Covid-19 Wave​

A brief update and your top questions answered​

KATELYN JETELINA JUL 18

​

I’m briefly coming out from hiding (a.k.a. summer break) to bring you a Covid-19 update. It seems like everyone has it right now (including the President). And I’m getting a ton of questions!
Let’s jump in.

We are in the middle of an infection wave.​

Covid-19 levels in wastewater—one of the best (only?) metrics of community spread these days—have reached the “high” category. This means that if you’re sick today, it’s likely Covid-19. This also means it’s time to get that indoor air moving and to wear a mask if you don’t want to get sick.

​

Data Source: CDC; Annotated by YLE
The West is leading the way with infections, and levels are higher than last summer’s peak. It’s hard to tell if the West is peaking. While Hawaii has already peaked after its huge infection wave, California and Oregon continue to increase considerably.
Other regions are following suit. In fact, 26 states have “high” or “very high” levels of Covid-19. (Enter your state here to see local levels.)

​

Covid-19 levels across states. Source: CDC
Severe disease is also increasing, but starting at low levels. Thanks to population immunity building, rates are not as high as last summer’s peak (or the summer before). (Note for those data gurus: The figure below is among a subset of hospitals that have consistently reported data over time. In other words, the lower hospitalization rate isn’t due to a change in reporting behaviors.)

​

Source: CDC; Annotated by YLE
In the UK, which always seems slightly ahead of the U.S. in waves, hospitalizations have peaked and remained lower than in Winter.

​

We’ve had a wave each summer. Why? ​

This is due to the combination of three things:

1. Behavior change. People move inside due to the heat, and most spread happens indoors.
2. Covid-19 keeps mutating quickly—about twice as much as flu. The latest variant, KP.3, specifically its descendant KP.3.1.1, is a little booger because it dropped a mutation on the spike protein, which seems to be effective in getting past our first immunity wall (called neutralizing antibodies.)
3. Waning immunity. ~20-30% of the U.S. population was infected with Covid-19 this past winter, which means the virus has plenty of pathways to find due to low immunity. Among states with mildCovid-19 winters, like Hawaii and Oregon, summer waves are very high.

​

Source: CDC; Annotated by YLE
I am surprised by how early this summer wave is (typically, we see it later in the summer) and how high infections are getting. I hoped we would see smaller and smaller summer infection waves each year. Alas, Covid-19 has different plans.

Should older people get the vaccine now or wait for fall? ​

We are seeing uncomfortable mortality rates among medically vulnerable people, like older adults in nursing homes, who are more than 6 months out from their last vaccine. For older adults who didn’t get their vaccine this spring, I suggest getting a vaccine now. But do it soon, as we want at leastfour months between this and the upcoming fall dose, so that it works best. Last year, the winter Covid-19 wave started in November.

How do I read the latest CDC guidance? ​

This is the first wave since the updated CDC Covid-19 guidance. As a reminder, if you get infected, CDC recommends approaching isolation in two phases:

• Phase 1: Stay home when sick until your fever resolves for 24 hours or your symptoms improve. But many people remain contagious beyond this timeframe, though, so…
• Phase 2: Use caution for five days by taking additional precautions (e.g., wear a mask; or test before seeing grandma at the nursing home).

But what is the best approach? Isolate until your at-home Covid-19 test turns negative, which could be anywhere between 3 and 15 days. Once it turns negative, you can be confident you’re no longer infectious. Unfortunately, many people cannot afford tests or to miss work for this long. If you leave isolation beforehand, please wear an N95.

​

Figure Source: Nature; Annotated by YLE

Is anything new happening with Paxlovid?​

Evidence shows that Paxlovid works for a small subgroup of people: medically vulnerable over 65 years and those who are not up-to-date on Covid-19 vaccines.
Unfortunately, Paxlovid is not as effective as we had hoped for everyone else. Evidence suggests that it doesn’t protect against long Covid, and it doesn’t decrease the number of days you’re sick (if you’re up-to-date on vaccines).

What about airplanes? ​

A lot of people are traveling this summer. Remember that the virus likes crowded, indoor areas with poor circulation, like airport terminals and planes before takeoff. Longer flights also pose more risk—for every 1-hour increase in flight duration, there is an additional 53% risk of infection.

Bottom line​

Covid-19 continues to do its thing. We are in the middle of an infection wave, and hopefully, it won’t find you, so you can continue to enjoy your summer. Given these news cycles, we could all certainly use a break.



"

 

[AprilBaby]

I have no idea where I got Covid again. The only people I have been around are family and no one else is sick. I was run down from excessive babysitting and I am immunocompromised so I guess it was inevitable. I had a vaccine 2.5 weeks ago, #6 or 7, lost count. Paxlovid is not without problems, my mouth tastes like sewer and everything else taste like hot peppers. Problem is the first two nights I can’t breathe at all out of my nose and I use CPAP so I get no sleep. Today I can breathe again. Thanks again Missy for the info. Regarding the RSV, is this a 1 time shot?

 

[missy]

"

IG Live July 19: Measles, Bird Flu, COVID, Oh My!​

— Experts unpack what recent outbreaks mean for public health​

by Gillian Booth, Social Media Editor, MedPage TodayJuly 18, 2024


While the threat of COVID-19 and long-COVID persistopens in a new tab or window, other infectious diseases have re-emerged or come into the spotlight this year.
In January, measles outbreaksopens in a new tab or window were reported in a handful of states, raising concerns among experts that this preventable disease might lose its elimination statusopens in a new tab or window. Meanwhile, childhood vaccineopens in a new tab or window exemptions and growing vaccine hesitancy have led to renewed calls for awareness and advocacyopens in a new tab or window.
This spring, H5N1 caught the world's attention with unprecedented outbreaks in mammalsopens in a new tab or window, including dairy cattle in the U.S. In April, public health officials announced the first known mammal-to-human caseopens in a new tab or window of H5N1 in a dairy farm worker in Texas. Since then, several more casesopens in a new tab or window have emerged.

Experts have voiced concerns about the availability of H5N1 protections such as tests, vaccinesopens in a new tab or window, and antivirals. And some worry the U.S. isn't doing enough to get ahead of any potential larger outbreak in humans.
Join us live as expert epidemiologists unpack the recent headlines surrounding these infectious disease outbreaks.
Featuring:
Jeremy Faust, MD (Moderator), editor-in-chief at MedPage Today(@jeremysamuelfaustopens in a new tab or window)
Katelyn Jetelina, PhD, MPH, author of "Your Local Epidemiologist" newsletter (@your_local_epidemiologistopens in a new tab or window)
Katrine Wallace, PhD, epidemiologist and adjunct assistant professor in the Division of Epidemiology and Biostatistics & Division of Community Health Sciences in the School of Public Health at the University of Chicago

"

 

[missy]

I have no idea where I got Covid again. The only people I have been around are family and no one else is sick. I was run down from excessive babysitting and I am immunocompromised so I guess it was inevitable. I had a vaccine 2.5 weeks ago, #6 or 7, lost count. Paxlovid is not without problems, my mouth tastes like sewer and everything else taste like hot peppers. Problem is the first two nights I can’t breathe at all out of my nose and I use CPAP so I get no sleep. Today I can breathe again. Thanks again Missy for the info. Regarding the RSV, is this a 1 time shot?

"For now, only one dose of the RSV vaccine is recommended. So far, RSV vaccines appear to provide some protection for at least two RSV seasons. Additional evaluation is planned to assess how long the protection lasts and whether additional doses will be needed."

RSV vaccines: Questions patients may have and how to answer

Respiratory syncytial virus (RSV) seasons vary each year, but this year there are RSV vaccines to help reduce risk for severe illness. Learn more.

www.ama-assn.org

 

[missy]

"

Long COVID Risk Has Fallen, Largely Attributable to Vaccine Rollout​

— However, metabolic and gastrointestinal sequelae increased among the unvaccinated​

by Katherine Kahn, Staff Writer, MedPage TodayJuly 18, 2024

The risk of developing long COVID, or post-acute sequelae of COVID-19 (PASC), has decreased substantially over the course of the pandemic, according to an analysis of Veterans Affairs data.
During the pre-Delta era, there were 10.42 cases of long COVID per 100 unvaccinated people at 1 year after COVID-19 infection, decreasing to 9.51 cases during the Delta variant era, and dropping to 7.76 cases per 100 unvaccinated people during the Omicron era, Ziyad Al-Aly, MD, of the VA St. Louis Health Care System in Missouri, and colleagues reported in the New England Journal of Medicineopens in a new tab or window.

Rates of long COVID among people who had received a vaccine were lower, and also decreased over time. During the Delta era, there were 5.34 cases of long COVID per 100 vaccinated people 1 year after infection, dropping to 3.5 cases per 100 people during the Omicron era.
"The good news is that PASC declined," Al-Aly told MedPage Today. "But literally millions of people get infected in the U.S., and many more around the world, so 3.5% is sizeable when multiplied by the number of COVID infections."
Of note, another recent studyopens in a new tab or window found that about 7% of adults living in the community report ever having long COVID as of early 2023.
In a decomposition analysis, Al-Aly and colleagues found that about 72% (95% CI 69.50-74.43) of the decrease in the cumulative risk of long COVID between the Omicron era and earlier eras could be attributed to vaccines and about 28% (95% CI 25.57-30.50) could be attributed to era-related effects, such as changes in virus pathogenicity. "These findings suggest that vaccine uptake will be key to maintaining the lower cumulative incidence of PASC relative to earlier phases of the pandemic," Al-Aly and colleagues wrote.

Despite the overall decrease, the residual risk of long COVID, even among vaccinated persons infected during the Omicron era, suggests that new cases of long COVID will probably continue to occur, Clifford Rosen, MD, of the MaineHealth Institute for Research in Scarborough, wrote in an accompanying editorialopens in a new tab or window.
"What are the messages from this study?" Rosen queried. "First, vaccinations can prevent many but not all cases of long COVID. Second, viral variants influence the risk of PASC."
Researchers also looked to see if individual health outcomes associated with long COVID had changed over time. They analyzed rates of cardiovascular, coagulation and hematologic, pulmonary, neurologic, metabolic, gastrointestinal, mental health, kidney, musculoskeletal, and fatigue disease categories. Although there was an overall decline in many sequelae associated with long COVID, the incidence for gastrointestinal, metabolic, and musculoskeletal disorders increased during the Omicron era among unvaccinated individuals.
"Long COVID in the pre-Delta and Delta era was actually different than long COVID that's happening in the Omicron era," Al-Aly said. "That tells us that not only is the risk quantitatively changing over time, but also that the disease itself has its own fingerprint -- it's not the same disease."

"The study suggests that new cases of PASC may continue unabated, owing to a potentially greater prevalence of metabolic dysfunction and its associated coexisting conditions among persons infected during the Omicron era," Rosen wrote. "Taken together, changes in the clinical presentation of long COVID are a function of 'points in time' and must be considered in any future trial or study design, as well as in clinical assessments."
Researchers analyzed health records of 441,583 veterans who were diagnosed with COVID-19 infection between March 2020 and the end of January 2022 and also included over 4.7 million non-infected controls. The study included five cohorts that included unvaccinated people with COVID-19 infected with the original strain in 2020 (n=206,011), the Delta variant in 2021 (n=54,002), and the Omicron variant in 2022 (n=40,367), and vaccinated people infected with the Delta variant (n=56,260) or the Omicron variant (n=84,943).
The study had several limitations. The population consisted primarily of older white male U.S. veterans and the study did not evaluate data on long COVID beyond January 2022. Moreover, the study may have missed confounding variables that could have led to misclassification of COVID-19 infection status.
Despite these limitations, the study provides "insight into the epidemiology of a complex disorder and may help guide clinicians in understanding the perplexing clinical course of PASC," Rosen concluded in his editorial.

• 
  
  Katherine Kahn is a staff writer at MedPage Today, covering the infectious diseases beat. She has been a medical writer for over 15 years.

Disclosures
The study was supported by the Department of Veterans Affairs.
Al-Aly reported being a consultant for Gilead and Pfizer. Another co-author reported ties to industry.
Rosen is an associate editor at the New England Journal of Medicine.
Primary Source
New England Journal of Medicine
Source Reference: opens in a new tab or windowXie Y, et al "Postacute sequelae of SARS-CoV-2 infection in the pre-Delta, Delta, and Omicron eras" N Engl J Med 2024; DOI: 10.1056/NEJMoa2403211.
Secondary Source
New England Journal of Medicine
Source Reference: opens in a new tab or windowRosen CJ "Viral variants, vaccinations, and long Covid -- new insights" N Engl J Med 2024; DOI: 10.1056/NEJMe2407575.

"

 

[AprilBaby]

Thanks again!

 

[missy]

Thanks again!

You’re very welcome Aprilbaby
Feel better soon

 

[missy]

"
Long COVID Risk Has Dropped Since Start of Pandemic
Ralph Ellis
July 19, 2024


Your chances of developing long COVID have significantly decreased since the pandemic began, offering a glimmer of hope and a sign of progress in the ongoing battle against the virus.

That's according to a new study published in The New England Journal of Medicine. Researchers at Washington University in St. Louis, who conducted the study, said that the drop was caused by vaccinations and changes in the virus itself.

"You can see a clear and significant difference in risk during the delta and omicron eras between the vaccinated and unvaccinated," Ziyad Al-Aly, MD, director of the Clinical Epidemiology Center at the VA St. Louis Health Care System and head of the research and development service, said in a statement. "So, if people think COVID is no big deal and decide to forgo vaccinations, they're essentially doubling their risk of developing long COVID."


Researchers analyzed the health records collected from March 1, 2020, through January 31, 2022, for 441,583 veterans who were infected with COVID-19 and 4.7 million veterans who were not infected.

Among unvaccinated people, long COVID was developed by 10.4% infected with the original strain of COVID, 9.5% infected with the Delta strain, and 7.7% infected with Omicron.

Among vaccinated people, long COVID occurred in 5.3% of those infected with the Delta strain and 3.5% of those infected with Omicron.


Al-Aly noted that among people infected with the Omicron strain, the chances of heart, brain, kidney, and lung problems declined while the risk of problems with metabolic function and the GI system increased.

"Each variant has its own fingerprint," Al-Aly said. "The original virus hit the respiratory system hard. Omicron targeted metabolic and GI issues. It's important because while the risk of long COVID is quantitatively lower, a person can be at a higher risk of developing an illness based on the part of the body that the COVID variant targets."

With long COVID, symptoms persist months or years after infection. Common symptoms include extreme fatigue, shortness of breath, loss of the sense of smell, and muscle aches.


According to the CDC's Household Pulse Survey, 18.4% of American adults say they've experienced long COVID at some point.

"

 

[missy]

"

Cold, Flu Virus Can Trigger Long COVID Relapses​

People who have recovered from long COVID can suffer relapses or flare-ups from new viral infections — not just from COVID but from cold, flu, and other viral pathogens, researchers have found.
In some cases, they may be experiencing what researchers call viral interference,something also experienced by people with HIV and other infections associated with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).
Clinical studies on the issue are limited, but patients, doctors, and researchers report many people who previously had long COVID have developed recurring symptoms after consequent viral infections.

Viral persistence — where bits of virus linger in the body — and viral reactivation remain two of the leading suspects for Yale researchers. Viral activation occurs when the immune system responds to an infection by triggering a dormant virus.
Anecdotally, these flare-ups occur more commonly in patients with long COVID with autonomic dysfunction — severe dizziness when standing up — and other symptoms of ME/CFS, said Alba Azola, MD, a Johns Hopkins Medicine rehabilitation specialist who works with patients with long COVID and other "fatiguing illnesses."

At last count, about 18% of those surveyed by the Centers for Disease Control and Prevention said they had experienced long COVID. Nearly 60% of those surveyed said they had contracted COVID-19 at least once.

Azola said that very afternoon she had seen a patient with the flu and a recurrence of previous long COVID symptoms. Not much data exist about cases like this, she said.
"I can't say there is a specific study looking at this, but anecdotally, we see it all the time," Azola said.
She has not seen completely different symptoms; more commonly, she sees a flare-up of previously existing symptoms.
David Putrino, PhD, is director of Rehabilitation Innovation for the Mount Sinai Health System in New York City. He treats and studies patients with long COVID and echoes what others have seen.
Patients can "recover (or feel recovered) from long COVID until the next immune challenge — another COVID infection, flu infection, pregnancy, food poisoning (all examples we have seen in the clinic) — and experience a significant flare-up of your initial COVID infection," he said.
"Relapse" is a better term than reinfection, said Jeffrey Parsonnet, MD, an infectious diseases specialist and director of the Dartmouth Hitchcock Post-Acute COVID Syndrome Clinic, Lebanon, New Hampshire.
"We see patients who had COVID-19 followed by long COVID who then get better — either completely or mostly better. Then they've gotten COVID again, and this is followed by recurrence of long COVID symptoms," he said.
"Every patient looks different in terms of what gets better and how quickly. And again, some patients are not better (or even minimally so) after a couple of years," he said.

Patients Tell Their Stories​

On the COVID-19 Long Haulers Support Facebook group, some of the many of the 100,000 ask about viral reactivation. Delainne "Laney" Bond, RN, who has battled postinfection chronic illness herself, runs the Facebook group. From what she sees, "Each time a person is infected or reinfected with SARS-CoV-2, they have a risk of developing long COVID or experiencing worse long COVID. Multiple infections can lead to progressive health complications."
The posts on her site include many queries about reinfections. A post from Decemberincluded nearly 80 comments with people describing the full range of symptoms. Some stories relayed how the reinfection symptoms were short-lived. Some report returning to their baseline — not completely symptom-free but improved.
Doctors and patients say long COVID comes and goes — relapsing-remitting — and shares many features with other complex multisystem chronic conditions, according to a new National Academy of Sciences report. Those include ME/CFS and the Epstein-Barr virus.
As far as how to treat, Putrino is one of the clinical researchers testing antivirals. One is Paxlovid; the others are drugs developed for the AIDS virus.
"A plausible mechanism for long COVID is persistence of the SARS-CoV-2 virus in tissue and/or the reactivation of latent pathogens," according to an explanation of the research on the PolyBio Institute website, which is involved with the research.
In the meantime, "Long COVID appears to be a chronic condition with few patients achieving full remission," according to a new Academy of Sciences report. The report concludes that long COVID recovery can plateau at 6-12 months. They also note that 18-22% of people who have long COVID symptoms at 5 months are still ill at 1 year.

"

 

[missy]

"

New Tactic to Speed Long COVID Treatments to Patients​

Sara Novak


Kaila Trawitzki was diagnosed with long COVID in November 2020 and, since then, has never recovered. The Sacramento, California, software engineering consultant said her ongoing symptoms, as well as the cost and risk for travel, make most onsite clinical research trials off limits.
But last year, when scientists at Yale University, New Haven, Connecticut, started recruiting patients for a long COVID treatment trial that would be conducted remotely rather than on site, she signed up immediately. "Knowing I could do it from home was really appealing to me," said Trawitzki.
As many as 17 million people in the United States currently have long COVID, yet experts say trials have been slow to enroll patients, in part because traveling to central trial locations can be costly and difficult for people suffering from fatigue, nausea, shortness of breath, gastrointestinal issues, and more. The remote trials that allow participants to take most, if not all experimental therapies at home, allow even the sickest patients with long COVID to participate.
Researchers at Yale, and elsewhere, say remote trials could lead to greater participation and speed the development of sorely needed new treatments for those with long COVID.
Decentralized clinical trials (DCTs), where the research occurs outside of an academic site, became more popular during COVID-19 when travel restrictions and physical distances made onsite research more difficult. Not to mention that the technologies and ability to share data are improving.



DCTs are more efficient, avoid the risk for acute COVID reinfection, promote patient diversity, and lay the groundwork for how these types of trials — for long COVID and other conditions — will be conducted in the future.

The Yale study enlisted 100 patients with long COVID from across the country to determine whether 15 days of the antiviral Paxlovid would improve their symptoms. The medication arrived to patients by mail, and they didn't know whether their medication was Paxlovid or a placebo.
Patients took the study drug twice daily for 15 days and were told to record their symptoms every evening. A representative from the study also came to each patient's home to gather and record blood work, and some patients had their blood work done at a facility close to home. After the study, surveys were sent out periodically to check on patient symptoms.

Patient Accessibility​

Remote clinical trials like this one are critical for patients who are severely affected by long COVID, said Akiko Iwasaki, PhD, an immunologist and molecular biologist at Yale School of Medicine, New Haven, Connecticut, who worked on the remote Long COVID (PAX LC) Trial.
"Many of them are not healthy enough to visit a clinic, and this gives them the freedom to still enroll in a trial," said Iwasaki. "It's much less taxing on patients especially those who are house- or bed-bound, and there's no need to arrange travel."

A More Efficient Approach​

This more streamlined trial also reduces inefficiencies that come from having more than one academic center involved in a clinical trial, said Harlan Krumholz, MD, a cardiologist at Yale School of Medicine and principal investigator of the PAX LC Trial. Yale is the only academic center running the study.
"The more coordination necessary between trial sites, the more inefficiency and friction, creating added expense and sometimes delays," said Krumholz. "You have more control over how everything works when it's all centrally deployed and de-centrally implemented through a single site.

Risk for Reinfection​

Such an approach is also helpful because many patients with long COVID have a fear of reinfection, said Carolyn Bramante, MD, MPH, an assistant professor of medicine at the University of Minnesota Medical School, Minneapolis, whose research focuses on remotely delivered interventions.
"It's stressful to patients involved in onsite trials because of the concern of reinfection with being in person at a facility with sick patients, which can be a higher-risk setting," Bramante said.
Cindy Mahler, 49, a Houston area-based aerospace engineer, got long COVID after a serious bout with acute COVID in March 2020. Her symptoms worsened after reinfection in January 2022. She enrolled in the Yale trial in February, attracted to the fact that it wouldn't require her to travel.
"I still live my life to protect my immune system," said Mahler. "I don't want to get sick with anything because I want to continue making progress and getting stronger."
Mahler's concerns are well founded, according to an August 2023 study published in the International Journal of Molecular Sciences. It showed that the risk for cardiac, pulmonary, or neurological complications in patients with long COVID increased with each COVID-19 reinfection.

Promoting Diversity​

The Yale study has also been able to reach rural communities and participants who might not have had access to these kinds of trials before, said Iwasaki, the Yale biologist.
The hope is that some of the key barriers — like the cost of travel and time off from work, which make it difficult for these underrepresented groups to enroll — are removed when a trial is remote.

A lack of diversity in long COVID clinical trials has been a concern among researchers from the start because it's hard to have robust knowledge of a treatment if it hasn't been tested on a wide variety of people. A December 2022 article published in JAMA Internal Medicinefound that female, Asian, Black, and Hispanic participants were underrepresented in COVID treatment trials.

Laying the Groundwork​

Additionally, the hope is that, with a better understanding of how to run DCTs, laboratories can transition the model to all sorts of studies.
"We created a decentralized trial across the entire country under the scrutiny of regulatory compliance," said Krumholz.

Compliance matters because if the data aren't compliant with the US Food and Drug Administration, then they can't be used by pharmaceutical companies seeking agency approval for new treatments. Krumholz said that this will open the door to doing many more experiments so that we can learn faster and be able to better treat patients with long COVID.
"It's like Kitty Hawk — it flies, and now we need to get fleets of these planes in the air," he said.
Both Trawitzki and Mahler felt that their symptoms improved after the trial, though they don't yet know whether they were given Paxlovid or a placebo and won't find out until next month. But one thing they know for sure is that the Yale study gave them hope — hope that they are or will get better, and hope for the system as a whole.
For the first time, they felt like they were being heard, and that people finally understood that, especially in this patient population, traveling across the country to do clinical trials is often unrealistic.
"I felt really supported throughout the study," said Trawitzki.

"

 

[missy]

"

Long COVID & ME/CSF: The Similarities are Uncanny​

Annie Lennon


An estimated two million people in England and Scotland were experiencing symptoms of long COVID as of March 2024, according to the Office for National Statistics. Of these, 1.5 million said the condition was adversely affecting their day-to-day activities.
As more research emerges about long COVID, some experts are noticing that its trigger factors, symptoms, and causative mechanisms overlap with myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS).
ME/CFS is characterised by severe fatigue that does not improve with rest, in addition to pain and cognitive problems. One in four patients are bed- or house-bound with severe forms of the condition, sometimes experiencing atypical seizures, and speech and swallowing difficulties.
Despite affecting an estimated 250,000 people in the UK and around 2 million people in the European Union (EU), it is a relatively poorly funded disease research area. Increased research into long COVID is thus providing a much-needed boost to ME/CFS research.

Dr Charles Shepherd
“What we already know about the possible causation of ME/CFS is helping research into the causes of long COVID. At the same time, research into long COVID is opening up new avenues of research that may also be relevant to ME/CFS. It is becoming a two-way process,” Dr Charles Shepherd, honorary medical adviser to the UK-based ME Association, told Medscape News UK.



While funding remains an issue, promising research is currently underway in the UK to improve diagnosis, treatment, and understanding of the pathology of ME/CFS.

Viral Reactivation​

Dr David Newton is research director at ME Research UK. “Viral infection is commonly reported as a trigger for [ME/CFS, meaning that the disease] may be caused by reactivation of latent viruses, including human herpes viruses and enteroviruses,” he said.
Herpes viruses can lie dormant in their host’s immune system for long periods of time. They can be reactivated by factors including infections, stress, and a weakened immune system, and may cause temporary symptoms or persistent disease.
A 2021 pilot study found that people with ME/CFS have a higher concentration of human herpesvirus 6B (HHV-6B) DNA in their saliva, and that concentration correlates with symptom severity. HHV-6B is a common virus typically contracted during infancy and childhood.
A continuation of this research is now underway at Brunel University to improve understanding of HHV-6B’s role in the onset and progression of ME/CFS, and to support the development of diagnostic and prognostic markers, as well as therapeutics such as antiviral therapies.

Mitochondrial Dysfunction​

Shepherd explained that there is now sound evidence demonstrating that biochemical abnormalities in ME/CFS affect how mitochondria produce energy after physical exertion. Research is thus underway to see if treating mitochondrial dysfunction improves ME/CFS symptoms.
A phase 2a placebo-controlled clinical trial from 2023 found that AXA1125, a drug that works by modulating energy metabolism, significantly improved symptoms of fatigue in patients with fatigue-dominant long COVID, although it did not improve mitochondrial respiration.

Betty Raman
“[The findings suggest] that improving mitochondrial health may be one way to restore normal functioning among people with long COVID, and by extension CFS,” study author Betty Raman, associate professor of cardiovascular medicine at the University of Oxford, told Medscape News UK. She noted, however, that plans for a phase III trial have stalled due to insufficient funding.
Meanwhile, researchers from the Quadram Institute in Norwich and the University of East Anglia are conducting a pilot study to see if red light therapy can relieve symptoms of ME/CFS. Red light can be absorbed by mitochondria and is used to boost energy production. The trial will monitor patients remotely from their homes and will assess cognitive function and physical activity levels.

Gut Dysbiosis​

Rik Haagmans
Many studies have found that people with ME/CFS have altered gut microbiota, which suggests that changes in gut bacteria may contribute to the condition. Researchers at the Quadram Institute will thus conduct a clinical trial called RESTORE-ME to see whether faecal microbiota transplants (FMT) can treat the condition.
Rik Haagmans is a research scientist and PhD candidate at the Quadram Institute. He told Medscape News UK: “Our FMT studies, if effective, could provide a longer lasting or even permanent relief of ME/CFS, as restoring the gut microbial composition wouldn’t require continuous medication,” he said.

Biobank and Biomarkers​

Caroline Kingdon
Europe’s first ME/CFS-specific biobank is in the UK and is called UKMEB. It now has more than 30,000 blood samples from patients with ME/CFS, multiple sclerosis, and healthy controls. Uniquely, it includes samples from people with ME/CFS who are house- and bed-bound. Caroline Kingdon, RN, MSc, a research fellow and biobank lead at the London School of Hygiene and Tropical Medicine (LSTHM), told Medscape News UK that samples and data from the UKMEB have been provided to research groups all over the world and have contributed to widely cited literature.
One group making use of these samples is led by Dr Fatima Labeed, senior lecturer in human biology at the University of Surrey. Labeed and her team are developing a diagnostic test for ME/CFS based on electrical properties in white blood cells.
“To date, studies of ME/CFS have focused on the biochemical behaviour of cells: the amount and type of proteins that cells use. We have taken a different approach, studying the electrical properties,” she explained to Medscape News UK.

Dr Fatima Labeed
Her research builds on initial observations from 2019 that found differences in the electrical impedance of white blood cells between people with ME/CFS and controls. While the biological implications remain unknown, the findings may represent a biomarker for the condition.
Using blood samples from the UKMEB, the researchers are now investigating this potential biomarker with improved techniques and a larger patient cohort, including those with mild/moderate and severe forms of ME/CFS. So far, they have received more than 100 blood samplesand have analysed the electrical properties of 42.
“Based on the results we have so far, we are very close to having a biomarker for diagnosis. Our results so far show a high degree of accuracy and are able to distinguish between ME/CFS and other diseases,” said Labeed.

Genetic Test​

Professor Chris Ponting
Another promising avenue for diagnostics comes from a research team at the University of Edinburgh led by Professor Chris Ponting at the university’s Institute of Genetics and Cancer. They are currently working on DecodeMe, a large genetic study of ME using data from more than 26,000 people.
“We are studying blood-based biomarkers that distinguish people with ME from population controls. We’ve found a large number – including some found previously in other studies – and are writing these results up for publication,” said Ponting. The results should be published in early 2025.

The Future ​

Sonya Chowdhury
While research into ME/CFS has picked up pace in recent years, funding remains a key bottleneck.
“Over the last 10 years, only £8.05m has been spent on ME research,” Sonya Chowdhury, chief executive of UK charity Action for ME told Medscape News UK. She believes this amount is not equitably comparable to research funding allocated to other diseases.
In 2022, the UK government announced its intention to develop a cross-government interim delivery plan on ME/CFS for England, however publication of the final plan has been delayed numerous times.
Shepherd agreed that increased funding is crucial for progress to be made. He said the biggest help to ME/CFS research would be to end the disparity in government research funding for the disease, and match what is given for many other disabling long-term conditions.
“It's not fair to continue to rely on the charity sector to fund almost all of the biomedical research into ME/CFS here in the UK,” he said.
Annie Lennon is a medical journalist. Her writing appears on Medscape, Medical News Today, and Psych Central, among other outlets.

"

 

[missy]

"

Covid is going around...

Do I need a boost?​

I got the original two Covid shots, and later I got three boosters. The last one was in October 2023. I’m 69. Should I get another shot now before I travel to Europe this summer? — Jacob, New York, New York For what feels like the umpteenth jillion time, Covid is on the rise in the US. President Joe Biden had it. All those people severely coughing on the subway probably have it. The summer surge is officially here to threaten your vacation. New shots are expected in early fall, says Katrine Wallace, an epidemiologist at University of Illinois at Chicago. The Centers for Disease Control and Prevention has already recommended those for everyone six months and older and final FDA approval is pending. “These new vaccines will be important for people to get because they will be updated from the previous version,” says Wallace. The vaccines have been tweaked to better fight the FLiRT variants of the virus that seem to be driving the current surge. So what you should be doing right now, when the virus is on the rise and many people’s fall boosters have begun to wear off? “Given that the new, updated vaccine will be available shortly, most Americans with lower risk profiles may want to hold out for the new one,” says Wallace. If you’re in a higher risk category — such as being older than 65, pregnant or immunocompromised — the CDC recently sent a newsletter suggesting it might be worth considering getting another shot now. (Getting another shot now, though, Wallace notes, could delay eligibility for the updated shot come fall.) “Another dose of the existing vaccine may be a good plan for the person asking this question, as a 69-year-old who will be doing international travel,” says Wallace. — Kristen V. Brown "

 

[missy]

"

Paxlovid, Vitamin Supplements Show Promise With Long COVID
David Brzostowicki
July 29, 2024

Paxlovid, an antiviral approved last year to treat acute infections of COVID-19, is showing great potential as a new treatment for long COVID and may be the most promising experimental therapy now being studied for treating the condition.

New research offers strong evidence that Paxlovid provides significant benefits for COVID-19 patients who are at high risk for severe or prolonged disease, particularly older adults and those who are immunocompromised, said Lisa Sanders, MD, medical director of Yale's Long COVID Multidisciplinary Care Center, New Haven, Connecticut.

"We all know that long COVID is a disease smorgasbord of illnesses that have been somehow triggered by COVID. So, the question is, are there some types of these disorders that can respond to Paxlovid?" Sanders said.


Some patients have also benefitted from supplements such as N-acetyl cysteine (NAC), as well as vitamins B, C, D and alpha lipoic acid, in which the risks are low and there are potential benefits, Sanders said.

As researchers continue to study new treatments for long COVID, for which there are no standard approved therapies, Sanders suggested doctors might turn to Paxlovid and other promising therapeutics that have shown benefits in preliminary study findings.

A study published last year by JAMA Internal Medicine reviewed the charts of nearly 300,000 veterans with severe acute COVID infections. The study found that Paxlovid treatment reduced the likelihood of developing long COVID. But a more recent study at Stanford University, Palo Alto, California — the STOP-PASC trial— did not find Paxlovid improved symptoms when given to 155 patients who had already recovered from acute infection. Participants with long COVID symptoms — and who had on average recovered from acute infection around 16 months earlier — were given a 15-day course of Paxlovid. Common symptoms like fog, fatigue, and cardiovascular or gastrointestinal symptoms did not improve.


However, long COVID likely has multiple drivers. Viral persistence may still be at play for a subset of patients. This means that despite the fact that patients recover from acute infection, hidden reservoirs of SARS-CoV-2 are still present in the body, possibly bringing on long COVID symptoms. Which means Paxlovid may help some long COVID patients but not others, Sanders explained. That's why research needs to continue to identify the best cases for Paxlovid's use and to identify other treatments for those who do not benefit from Paxlovid.

The PAX LC trial at Yale suggests there may not be a one-size-fits-all treatment for the condition, but a range of factors that may determine the best therapy for individual patients. Led by Yale School of Medicine's Harlan Krumholz, MD, and Akiko Iwasaki, PhD, the study tested the effects of Paxlovid overall and was designed to determine who is most likely to benefit from antiviral treatment and gain further understanding of the immune response in Iong COVID. Results should be reported soon.

"This acknowledges one line of thinking that long COVID is caused by viral persistence," Sanders said. "Do these people have hidden reservoirs of the virus? The question is, are there people who seem to respond (to Paxlovid)? And if so, what characterizes these people?"


Low-Risk, High-Reward Supplements
Some of Sanders' colleagues at Yale are focusing on long COVID's neurological symptoms and neuropathogenesis. There's evidence showing these symptoms — notably brain fog — can be treated with supplements.

In 2022, a Yale study by Arman Fesharaki-Zadeh, MD, PhD, found promise in treating brain fog through a combination supplement of NAC and guanfacine — the latter developed by Yale neuroscientist, Amy Arnsten, PhD.

The two published their study in Neuroimmunology Reports in November 2023. NAC is available over the counter and patients can get a prescription for guanfacine off-label from their physician. Guanfacine is approved to treat high blood pressure by decreasing heart rate and relaxing blood vessels. But it's also been shown to treat attention-deficit/hyperactivity disorder (ADHD) and other cognitive issues.

Though NAC can treat respiratory problems, it's also commonly used to treat postconcussion symptoms. Fesharaki-Zadeh found that it helps treat brain fog, increases energy, and improves memory. When paired with guanfacine, substantial benefits were reported, such as better multitasking abilities and markedly improved organizational skills.

Sanders is now using NAC and guanfacine for patients in her clinic.

'Mitochondrial Enhancement' Through Vitamins
Sanders has also used a combination of alpha lipoic acid and vitamin C, and a combo of B vitamins that make up what's called a "mitochondrial enhancement regimen."

To treat a very common symptom like fatigue, Sanders prefers supplement combinations over other drugs like Modafinil or Adderall.

Modafinil is a central nervous system stimulant used to reduce extreme sleepiness due to narcolepsy or other sleep disorders. Adderall is an amphetamine also used to treat narcolepsy as well as ADHD. Both work on your sleep and alertness, but long COVID affects the whole body, causing a physical fatigue similar to postexertional malaise (PEM) that isn't remedied by those kinds of drugs, as studies suggest what's involved in PEM is mitochondria, Sanders said.


PEM is a worsening of symptoms that occurs after minimal physical or mental exertion. These are activities that should be well tolerated, but PEM causes extreme fatigue and flu-like symptoms. It's become a hallmark symptom of long COVID after having already been a key diagnostic factor in myalgic encephalomyelitis/chronic fatigue syndrome.

As Sanders noted in her long COVID blog, which tracks the latest research and treatment options for doctors who treat long COVID patients, previous studies have shown low vitamin D levels may not only increase the risk for severe COVID-19 but delay recovery from long COVID. Those without long COVID had higher levels of vitamin D compared with long COVID patients. Vitamin D is known to boost the immune system.

Sanders found that those with vitamin D deficiencies are most likely to benefit from this approach. For people who don't have sufficient sun exposure, which prompts the production of vitamin D, she says supplementation with 1000 IUs of vitamin D3 daily is enough for most adults.


Research is also currently being underway on the use of the diabetes drug metformin in people with acute COVID infections to determine if it may reduce the likelihood of developing long COVID. In a recent long COVID clinical trial, early outpatient COVID-19 treatment with metformin decreased the subsequent risk for long COVID by 41.3% during 10-month follow-up.

Other New Treatments Under Study
Sanders believes the foundation for many of long COVID's symptoms could be neurological.

"I think that long Covid is probably a neurologic disorder," Sanders said.


Lindsey McAlpine, MD, director of the Yale Medicine NeuroCovid Clinic, is focusing on neuropsychiatric long COVID and the causes of neurologic postacute sequelae of SARS-CoV-2 infection (neuro-PASC). Symptoms of neuro-PASC include cognitive impairment, headaches, and dizziness.

"Lindsey is trying to see which parts of the brain are involved and see if there are phenotypes of brain abnormalities that match up with clinical abnormalities," Sanders said.

The National Institute of Neurological Disorders and Stroke recently awarded her a 5-year K23 grant to support her ongoing study, "Magnetic Resonance Imaging Biomarkers of Post-COVID-19 Cerebral Microvascular Dysfunction."

Utilizing advanced MRI techniques to identify microvascular dysfunction biomarkers in the brain, McAlpine hopes to unearth and better understand the pathophysiology behind neurological issues post covid.

Many of McAlpine's patients with cognitive symptoms have responded well to NAC and guanfacine.

Still, the hope is that her brain-imaging studies will bear fruit that leads to a better understanding of long COVID and new treatment methods.

"

 

[missy]

From Bloomberg dot com

"

Masks, outdoor activities and air purifiers​

It’s been more than two years since I was infected with Covid which developed into long Covid, and my life has not been the same since. It was my first positive test, but it’s possible that I caught the virus in March 2020 when mass testing wasn’t yet available. Back then, I had already started self-isolating before national lockdowns were implemented and I didn’t think much of this bout of sickness until years later, when I heard that repeat infectionscould increase the risk of developing long Covid. As one of millions of people around the world suffering from long Covid, I have been learning how to live with the condition. I avoid alcohol and late nights, and have to dial back on socializing on the days when I’m feeling triggered. That’s why the idea of getting infected again terrifies me, because it can undo the progress I’ve made during my long Covid recovery. Getting sick in general can cause problems: last year, I developed hives after a common cold and now take anti-histamines every day to keep the itchiness away. “It seems like each new infection could potentially be a new situation for the virus to potentially down-regulate the immune system and create a better environment for the reactivation of other dormant pathogens,” says Amy Proal, president of PolyBio Research Foundation, a non-profit that facilitates research into chronic, infection-associated conditions. The idea that getting regularly infected would only strengthen the immune system is “wishful thinking,” she added. Now, I take extra precautions compared to pre-pandemic times. If a friend tells me they’re sick — even if they say it’s mild or that they’re feeling fine — I’ll suggest catching up another time. I’ll order my own food when out for a meal with others, or insist on using serving spoons if we’re sharing some dishes. At the first sign of a sore throat or swollen glands, I use a nasal spray designed to prevent full-blown colds. Covid is spread via airborne particles and droplets. So to avoid getting reinfected, Proal suggests wearing a well-fitted N95 respirator mask particularly in crowded spaces, socializing outdoors where air movement is better, opening windows when inside to the extent that it’s possible and using HEPA filters to improve indoor air quality. “Clean your air,” she says. “You can just be in a room with someone who’s sick and if they’re breathing enough into the air and the air’s not getting turned over, it just kind of clouds like a cigarette smoke cloud.” — Lisa Pham "

 

[missy]

"

Docs Should Start Getting Ready For Upcoming Respiratory Virus Season​

— Updated COVID vax coming soon, not too early to pre-order vaccines, CDC director says​

by Katherine Kahn, Staff Writer, MedPage Today

Physicians should start preparing now for the upcoming respiratory virus season, according to the CDC in a webinar hosted by Bruce Scott, MD, president of the American Medical Association (AMA) on Tuesday.
The webinar focused on strategies for getting patients vaccinated for COVID-19 and flu and putting into action the Advisory Committee on Immunization Practices' (ACIP) updated RSV vaccination recommendationsopens in a new tab or window. The webinar can be viewed in its entirety hereopens in a new tab or window.

CDC director Mandy Cohen, MD, MPH, reviewed vaccine recommendations for the 2024-2025 respiratory virus season. Everyone ages 6 months and older should get an updated COVID-19 vaccine and updated influenza vaccine, Cohen said.
"We're going to see an updated COVID-19 and flu vaccine here in just a few weeks," she noted. "The flu [vaccine] is actually starting to be available right now, so you can be getting that into your practice ... right now is a great time to pre-order."
Cohen also discussed the updated adult RSV vaccination recommendationsopens in a new tab or window issued in June. All adults, ages 75 and older, and those ages 60 to 74 with risk factors that might lead to severe respiratory disease should get a one-time RSV vaccine (Arexvyopens in a new tab or window, Abrysvoopens in a new tab or window, mResviaopens in a new tab or window).
"Particularly, I want to highlight those who are in a nursing home," Cohen pointed out. "We are seeing more RSV circulating in nursing homes. We really want to make sure anyone who is residing in that group setting is protected from RSV going into this season."

In a Q&A session, Demetre Daskalakis, MD, MPH, director of the CDC's National Center for Immunization and Respiratory Diseases, addressed co-administration of the COVID-19, influenza, and RSV vaccines. "Bottom line is, that's a best practice. Co-administering these vaccines is really critical, especially for people where you only have one shot," for getting them vaccinated. "It is safe. We have a long history of COVID and flu [vaccine] co-administration. The data also support the co-administration of RSV vaccine at the same time." Also, administering the vaccines simultaneously does not seem to blunt the immunologic response of any of the vaccines, he emphasized.
For infants, there are two options for RSV immunization. One option is for pregnant mothers to get the maternal RSV vaccineopens in a new tab or window (Abrysvo only) between 32 and 36 weeks of gestation; it is usually given sometime between September through January. Another optionopens in a new tab or window is for infants under age 8 months, and children 8-19 months with risk factors, to receive the monoclonal antibody nirsevimab (Beyfortus). Nirsevimab is usually administered during the RSV season from October through March.

"Ordering and offering immunizations in your clinics is one of the most powerful ways to improve vaccine confidence and increase immunization rates," Cohen said, because convenience is a top reason for patient acceptance and reduces missed opportunities for immunization. The CDC is now providing online immunization and vaccine product summariesopens in a new tab or window, including ordering and availability information.
Cohen recommended that practices consider appointing a vaccine champion to streamline office vaccination protocols. "That really helps to make sure your office is set up and prepared for having conversations with patients about vaccination as well as not missing an opportunity to give out those doses," she noted." So every time someone walks into your office, it's an opportunity both to have that conversation and to make sure you're immunizing."
For patients who get vaccines in pharmacies, Cohen emphasized that it's important to "close the loop" by making sure pharmacists have all the patient information they need to administer vaccines -- for example, when ordering RSV vaccines, physicians should be sure to provide risk factors for patients ages 60-74 and gestational age for patients who are pregnant.

To address vaccine cost barriers among children, Cohen recommended clinicians participate in Vaccines for Childrenopens in a new tab or window program, which provides all ACIP-recommended vaccines to eligible individuals ages 18 and younger at no or low cost. For adults, Medicaid covers recommended vaccines without cost sharing. Medicare Part B covers flu and COVID-19 vaccines, she said. The RSV vaccine is covered under Medicare Part D, but patients need to get vaccinated at an in-network provider, as do those with Medicare Advantage plans and many of those who have private insurance.


"

 

[missy]

"

From Covid-19 Peaks to New Viral Threats: What You Need to Know​

State of Affairs​

KATELYN JETELINA

Happy August! I’m back from summer vacation. My little family explored all three gorgeous national parks in Washington State, which required much-needed unplugging.

The YLE team is refreshed and ready for the fall season! I hope you are, too. Let’s dive into the state of affairs.

Covid-19: Up, up, and away​

We are knee-deep in a substantial Covid-19 infection wave. Wastewater levels—a good indicator of community spread—remain high and continue to increase, especially in the South and the West, where levels are coming close to last winter's.

​

(CDC; annotations by YLE)
Thankfully, immunity keeps our hospitals from overflowing at this point, but severe disease trends continue to mirror infections. For example, in California, hospitalizations this summer are as high as last winter.

​

(Source: CDC; annotations by YLE)
This pattern—2024 summer rates reaching winter rates— is not unique to the U.S. Covid-19 hospitalizations in the U.K., Spain, and Australia all show similar trends.

​

Covid-19 hospitalizations trends across the globe
The height of this summer wave is surprising to me, as we would hope that summer waves get smaller and smaller over time. So, three unanswered questions are top of my mind:

1. Why is this happening? I don’t know. The newest subvariant doesn’t have so many mutations that I would predict this would happen. Vaccination rates are about the same as last year, which also wouldn’t explain it. Could this be due to the CDC changing its isolation guidelines to be more relaxed in February? Probably not, given similar patterns in other countries.
2. Will we have a milder winter? We can hope that the immunity we have built up will lead to a milder winter, which would be a welcome reprieve to health systems.
3. Are biannual waves the future? Many (including me) hypothesize Covid-19 will eventually become a winter virus, like flu. But clearly Covid-19 is still unpredictable and will likely take another decade to find a rhythm.

Other updates​

Epidemiologists are monitoring these other viral outbreaks. You have nothing to do, but here is an update so you can follow the scientific discovery ride.

H5N1 (bird flu): Continues to spread​

We are keeping an eye on H5N1 because of the potential for it to become a pandemic.

H5N1 continues to spread among animals. USDA has reported 171 dairy cow herds in 13 states with confirmed H5N1 infection.

​

Source: Helen Branswell (X)
Four big developments have occurred since the last YLE update.

1. More humans have been infected, but no onward spread. This year a total of 13 people have been infected with bird flu: four from sick dairy cows and nine from poultry. This is a lot of cases, considering U.S. had 1 H5N1 human case last year and zerobefore. The human tally recently increased thanks to a big outbreak in Colorado, when several workers got sick after culling (killing) infected poultry. As far as we can tell, this outbreak wasn’t because the virus mutated; instead, it was the environment—it was over 100 degrees at the farms, so workers didn’t wear PPE (understandably), and massive industrial fans to cool the area spread feathers (and virus). So far, cases have been mild (red eye and respiratory symptoms), and there is no ongoing human transmission.
2. We are missing human cases. Given our limited human (and animal) testing, it shouldn’t be a surprise that we are likely missing human cases. In Texas, scientists tested the blood of 14 previously symptomatic farm workers and found 2 workers had antibodies. This could be evidence that they had H5N1 at one point. (However, it’s also possible because of the type of test used that these antibodies reflect infections from seasonal flu [H1N1]). We don’t think there is an asymptomatic spread. Another study in Michigan tested the blood of 35 workers who were exposed to infected herds but never had symptoms, and none were positive.
3. There are no signs of it “burning out.” The genetic sequences of bird, cow, and human cases suggest the U.S. has created a new reservoir of H5N1 that can spill over into poultry and humans all year round.
4. All eyes are on the upcoming seasonal flu. If one of these farm workers gets infected with H5N1 while sick with seasonal flu, the risk of a pandemic skyrockets, as the virus can easily swap genes to become more adaptable to human spread. CDC is funding an extensive seasonal flu vaccine campaign for farmworkers to prevent a nightmare.

We still don’t have an updated CDC risk assessment of an H5N1 pandemic (called iRAT), which is surprising. (The last iRAT was published in April 2023 after minks were infected in Spain. They rated the pandemic risk as “moderate.”) The U.K. recently raised their risk assessment (from 3 → 4) given the U.S. outbreak.

​

Mpox (Monkeypox): Surging in Africa​

The WHO is considering naming the ongoing mpox outbreak a public health emergency of international concern.

Case counts continue to explode in Africa, with over 37,000 cases and 1,400 deaths. The Democratic Republic of Congo (DRC) has been the epicenter, accounting for over 96% of this year’s cases and deaths. The vast majority of deaths (85%) are among children. The Africa CDC has heightened its monitoring and declared the risk “high.”

In a surprising turn of events, mpox has mutated. Mpox is primarily divided into two clades (types): Clade I and Clade II. Clade I, found predominantly in Central African countries, tends to be more severe. The new strain, called Clade 1b, is severe and can be transmitted human to human.

Unfortunately, many patients in Africa lack the resources that can keep mpox at bay, like vaccinations, treatments, and access to care. In the United States, for example, where only Clade II—the less severe strain—is spreading, cases are far lower than in 2022. Even if the more severe strain landed in the U.S., we don’t think it would be as detrimental as it is in Africa.

​

Mpox cases in the United States; Graph by YLE

Bottom line​

Covid-19 infections are surging this summer. There are things you can do—stay up to date on vaccines, mask indoors and in crowded areas, and get that indoor air flowing. Concurrently, H5N1 continues to march into the upcoming flu season, increasing the risk of another pandemic, and WHO is considering another mpox emergency. As always, we’ll keep you updated as things change.

"