August in Covidlandia

Still riding that Olympic-sized wave.

Welcome back to some monthly highlights from a place I call Covidlandia, a forgotten land between black and white, carefree and cautious, pandemic beginning and end. Here I present recent news, scientific discoveries, and medical knowledge that caught my attention and that is of interest to primary care. I curate and comment, and realize that one human being cannot possibly keep up with everything. But I try to highlight useful, actionable stuff. January, February, March, April, May, June, July, and now August.

Covid is still infecting about 1,000,000 Americans a day. ~1 out of every 35 people is currently infected (1 million x 10 day illness / ~350 million Americans). The curve is bending downwards, though, which is good news. Back to school will prolong these high rates, but one well-respected forecaster predicts rates will be down 40% by early October. We will take it, but half of these large numbers is still large.

Here is a good graphic put out by the Pandemic Mitigation Collaborative:

Maybe ~1,000 Americans are dying of Covid per week based on several sources I read, but it’s hard to confirm since hospital reporting is no longer mandatory. Nonetheless we know that in general hospitalizations are up, as are new long Covid syndromes we can conservatively assume affect at least 5% of people each time they get sick, if not much higher. The Pandemic Mitigation Collaborative maintains this busy composite graphic, but it really tells you a lot, including stuff you’d rather not know:

In one of the data boxes you can see the estimate - the average American has had Covid 3 to 4 times (average comes out to 3.3).

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The new updated Covid shots are here

If we did not get caught up in the summer wave, we can choose to prime our immune systems against KP.2 and JN.1 variants now. If we did catch a recent case, waiting 3-4 months makes more sense. Pfizer and Moderna are in pharmacies, and Novavax was just approved so maybe another week on that? The targets of these shots are a little behind the current lineages going around, but are still pretty close on the evolutionary tree. Much closer than XBB shots first received last year. There are actually a lot of strident voices out there telling you and me not to get the vaccines, but cooler heads with much greater experience and expertise have come to the consensus that benefits still outweigh risks. Benefits are less infections for a while, less long Covid, and still incrementally less hospitalizations and deaths. By comparison, I’ve had over 40 flu shots, and I keep rolling up my sleeve until the evidence and experts tell me it’s not worth it. But don’t listen to me, or indeed any other individual. We are outranked by much smarter hive minds, including the CDC panels that work really hard to weigh the evidence, and the hundreds of researchers who observe and study the effects of these vaccines in real time in millions of people.

Do updated shots and boosters keep helping overall? The evidence that I’ve found is at least 60+ studies deep, and so far so good. I got mine yesterday. Moderna. Right arm sore and overall feeling a little achy.

My decision was also informed by the mild reactions I’ve had in the past, the back to school spread, no recent Covid infections, and my dispassionate faith in smart scientific people that inform primary care docs like me. Your calculation may be different.

Novavax can be tricky to find. A patient told me they got one last year at Costco. As of this writing Novavax is still not listed on the Costco pharmacy website, and the couple CVS/Rite Aid pharmacists I called were not sure when it would be delivered. Maybe a week? It does seem to be better tolerated for those with bad side effects, and the JN.1 variant it targets right now is not that far off the evolutionary tree from the KP’s.

Modern and Pfizer listed on Costco website, but not Novavax yet as of 9/1/2024

I should know more about my office supplies when I return next week.

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More free tests on the way

Not sure why these will be available towards the end of September, but better late than never. It’s worth stocking up on some rapid tests, freebies or purchased. It’s worth testing when you’re sick. That way you have options to consider in terms of treatment, and can protect other people by trying not to get them sick.

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Caring about Covid is socially awkward

The New York Times had a good piece last month about the problematic offramp from this pandemic. I really do see all sides: the strong desire to have some normalcy, the strong social pressures to let our guards down, the fact that each time we get this disease it’s a roll of the dice, for young and old, healthy and frail.

Five years into the Covid pandemic, a stark divide has emerged in how people respond to the virus, with many now treating it like a common cold despite surging cases and increased hospitalizations. This shift stems from growing immunity, fatigue with restrictions, and a collective overoptimistic fiction, creating social tensions as some still exercise caution. The CDC's relaxed guidelines reflect this new reality, but epidemiologists warn the virus remains unpredictable, leaving individuals to navigate a complex landscape where former norms clash with a desire to return to pre-pandemic life.

In other words, it sucks to be careful, and it sucks to not be careful. I get it. Especially with back to school it’s going to be impossible to be as careful as I would like to be.

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More studies showing benefit from the most recent boosters

It is hard to keep track of all the studies showing the benefits of staying up to date with vaccines and boosters. I did a post on this last week in which I dropped a practically unreadable number of studies (60+), more as a strength-in-numbers display. Nonetheless here are two more studies from last month:

This study published in the journal Influenza, looked at the effectiveness of the adapted XBB.1.5 COVID-19 vaccine in Europe from October 2023 to January 2024. The study estimated a vaccine effectiveness (VE) of 49% against SARS-CoV-2 hospitalization, with slightly higher effectiveness in those aged 80 and above compared to those 60-79 years old. The VE declined over time, from 69% in the first 29 days to 40% at 60-105 days post-vaccination. It should be noted that this incremental benefit builds on top of the already decreased risks we have with prior shots and infections… though that protection wanes with time, too.

And a different study published in the journal Vaccine found an 80% reduction in hospitalization among women who received a Covid vaccination during pregnancy. Pregnant women are at higher risk of Covid complications such as hospitalization, intensive care unit admission, invasive mechanical ventilation, and death. They are also at increased risk of pregnancy-related complications including preeclampsia and emergency cesarean delivery. Their infants are at higher risk of preterm birth or being stillborn.

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Paxlovid keeps working, especially for higher risk people and when started early

The message is clear to me - antivirals still help. While they are usually studied in terms of reducing risks of death and hospitalization, reducing viral loads early has also been shown to reduce the risk of long Covid.

This study published last month in The Lancet found that even in 2022, with a combination of previous infections and vaccinations, Paxlovid is still worth taking:

In this matched cohort study of data from a large, integrated US health-care system, receipt of nirmatrelvir–ritonavir within 5 days of symptom onset was 80% effective in reducing the risk of hospital admission or death within 30 days of an outpatient positive SARS-CoV-2 test.

Irrespective of time of dispensing (within 5 days or not), nirmatrelvir–ritonavir was 54% effective in reducing the risk of hospital admission or death within 30 days.

To our knowledge, our study is one of the first large real-world effectiveness studies done during the BA.2 and BA.4 and BA.5 omicron waves in a broad representative patient population of mostly vaccinated adults that includes people younger than 65 years.

And when patients were tested and started treatment the same day, reduction in hospitalization and death was up to 90%. This equates to a number-needed-to-treat of just 20 people to reap this benefit.

While on call, I just prescribed it this morning to an older patient with Parkinson’s, and another with coronary artery disease. We are also trying metformin to hopefully further reduce risks of long Covid. And I’m not above recommending low tech nasal saline.

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Patients on Wegovy found to have a 33% less risk of dying from Covid

The weight loss drug Wegovy, already known to reduce cardiovascular risks in obese people, has now been shown to decrease the chances of dying from Covid-19 by about a third compared to placebo. The findings come from an analysis published in the Journal of the American College of Cardiology of the Select study which involved over 17,000 participants with obesity or overweight and heart disease. While the exact mechanism is unclear, researchers suggest that Wegovy may improve overall health, bolster the immune system, and reduce inflammation, making patients better equipped to handle severe Covid infections. Or it could be simply that reducing obesity reduced the risk of Covid.

Starting a medicine like Wegovy to help treat acute Covid infections would be pure speculation, and I think unlikely to help as much. This study looked at patients already on the medicine.

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Politics and policy matter

A new modeling study in JAMA Health Forum found that Covid-19 precautions, like mask mandates and vaccine requirements, could have saved as many as 250,000 lives in the United States by reducing excess deaths, or deaths that occur above what researchers predict for a typical time period. 

“If all states had imposed restrictions similar to those used in the 10 most restrictive states, excess deaths would have been an estimated 10% to 21% lower than the 1.18 million that actually occurred during the 2-year analysis period,” the study’s author wrote.

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Distrust of vaccinations

According to the latest national health survey by the Annenberg Public Policy Center, a growing number of Americans believe COVID-19 vaccine misinformation and are reluctant to get vaccinated or recommend vaccination to others.

Specifically:

• 28% of survey respondents mistakenly believed that Covid vaccines have caused thousands of deaths

• The proportion of respondents who mistakenly think that Covid vaccines change human DNA reached 15%

• Only 20% of those surveyed were somewhat or very worried that they or a family member will contract Covid

• 44% of respondents said they were "somewhat likely" or "very likely" to get a yearly Covid vaccine if the CDC recommended it

• Fewer Americans said they thought Covid vaccines were safe (66%) and effective (65%) than they thought the same about other vaccines

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An important editorial about the pandemic lessons not learned or politically undermined

This editorial, published in the New England Journal of Medicine, warns that the United States is repeating mistakes made during the COVID-19 pandemic in its response to the potential threat of H5N1 avian influenza. The authors argue that despite previous pandemic preparedness plans, the U.S. is showing similar weaknesses in testing, surveillance, and coordination between agencies and levels of government.

The post-pandemic landscape has seen a widespread push to curtail public health officials' authority through various means, including state laws restricting mask mandates and religious gathering limits, shifts in judicial review of health orders, Supreme Court decisions limiting federal agency powers, the overturning of the Chevron doctrine, and growing resistance to community-level mitigation measures, collectively hampering officials' ability to respond effectively to future public health emergencies.

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Covid vaccines saved 1.6 million lives in Europe

Vaccinations directly saved at least 1.6 million European lives, with 60% of those lives saved during the Omicron period, according to new estimates published in The Lancet Respiratory Medicine. The study, which analyzed vaccination efforts from December 2020 to March 2023 across 34 European countries, found that the first booster dose was most effective, saving 51% of all lives saved.

While 2.2 million COVID-19-related deaths were reported in Europe as of March 2023, experts suggest that the number of lives saved by vaccination may be an underestimate due to factors such as herd immunity effects and underreporting of Covid mortality.

Politics

Well, the DNC convention was a Covid mess, entangling several people like Hillary Clinton. The RNC convention was not any better, except that there was less Covid in July. It’s a bipartisan thing to ignore the pandemic when possible:

Yet two years removed from the pandemic’s crisis period, polling shows that Covid ranks far down the list of urgent voter priorities heading into November — if it shows up in surveys at all — with few Americans eager to revisit the painful memories of the pandemic era.

Did you know that Democratic VP nominee Tim Walz defeated a Republican opponent named Dr. Scott Jensen (a fellow family doctor) in the race for Governor of Minnesota in 2022? Dr. Scott Jensen was not a helpful person during the pandemic. Rather, he was harmful.

Leaders matters. Vote for good ones.

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They are coming for your right to wear a mask if you choose

Wearing a mask in Nassau County, NY is a now misdemeanor that includes a $1,000 fine and can include jail time. North Carolina enacted a similar ban.

Here are two excellent opinion pieces about this problem:

• Kaitlin Costello, writing for STAT News, details how mask bans, like the one in Nassau County, New York, disproportionately impact Americans with disabilities, particularly those who are immunocompromised, despite often including medical exemptions. She criticizes these bans for their subjective enforcement, potential to exacerbate racial disparities, and infringement on civil liberties, including the right to peaceful assembly. She argues that such bans not only threaten vulnerable populations but also undermine fundamental human rights and democratic values, especially in the context of an ongoing pandemic with low vaccination rates.

• Kelly, who also writes on Substack, speaks from within the context of her own medical issues. She also criticizes North Carolina and Nassau County, NY's recent bans on public masking, arguing that they are discriminatory, ableist, and dangerous, particularly for those with invisible illnesses or disabilities. She contends that medical exemptions are insufficient, as they require law enforcement to make medical judgments and may deter high-risk individuals from masking or being in public. She rightly concludes that masks are essential personal protective equipment for everyone, not just the vulnerable, and calls for public resistance against mask bans to protect community health and accessibility.

Again. Vote for your freedoms, bodily and otherwise.

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Long Covid overview

I’m just going to drop a quote from this All-Star team of Covid experts who published a landmark article in Nature this month about long Covid:

The cumulative global incidence of long COVID is around 400 million individuals, which is estimated to have an annual economic impact of approximately $1 trillion—equivalent to about 1% of the global economy. Several mechanistic pathways are implicated in long COVID, including viral persistence, immune dysregulation, mitochondrial dysfunction, complement dysregulation, endothelial inflammation and microbiome dysbiosis. Long COVID can have devastating impacts on individual lives and, due to its complexity and prevalence, it also has major ramifications for health systems and economies, even threatening progress toward achieving the Sustainable Development Goals. Addressing the challenge of long COVID requires an ambitious and coordinated—but so far absent—global research and policy response strategy.

Doctors should still be out there fighting the good fight, urging some personal degree of risk reduction, good ventilation when possible, staying up to date with vaccines, and treating Covid when it presents.

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Most common symptoms of long Covid

Two UK studies on long Covid reveal that fatigue, tiredness, and shortness of breath are the most common persistent symptoms among healthcare workers, significantly impacting their work and daily life. Pain emerged as the most prevalent and severe symptom among long-Covid patients referred to post-Covid clinics. The studies also found that demographic factors such as age, ethnicity, and education level influence symptom severity, with older adults, women, and non-White individuals experiencing more intense symptoms.

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Covid Olympics

It is a real testament to the elite training of many Olympic athletes that they could still compete with recent, or indeed current, Covid infections. It is also a real testament to the state of the world that such minimal mitigation protocols were in effect to protect said elite athletes and everyone else.

Noah Lyles may be the unforgettable face of these Olympics.

Salon published a piece about how his collapse underscores our collective denial about Covid, and former Surgeon General Jerome Adams wrote an opinion highlighting the Olympic failure to apply the knowledge and resources we’ve accumulated over the past 4 years.

I am concerned that many of these athletes will have sustained damage and diminished abilities from pushing through Covid infections to keep competing. We know that rest and gradual return to physical exertion reduce the risk of long Covid and muscle damage while recovering.

In my self-treatment post, previously I wrote the following:

…in some people, especially those developing long Covid, exercise can actually damage muscles and over stress mitochondria in the weeks during/after illness. This would be felt by the person as a new kind of post-exertional malaise, muscle pain or soreness out of proportion to the intensity of the exercise, or basically just feeling like crap after exercise. I also recall that early in the pandemic there were reports of athletes and others exerting themselves too vigorously in the month or two after Covid illness and then developing arrhythmias which can be lethal. So in summary, I’m going to listen to my body regarding exercise and not be dogmatic. I’ll probably take it down a notch for a month after illness.

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There are still no consensus blood tests for confirming long Covid

A large-scale study found that 25 routine clinical lab tests cannot reliably diagnose long Covid, suggesting that clinicians should focus on symptoms rather than lab results for diagnosis and treatment. This makes it tough for primary docs to firmly say, this is long Covid, without a bunch of other tests to exclude other conditions.

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Covid is not the only game in town

And finally, I would like to acknowledge that there’s a lot of other stuff on the radar right now. West Nile virus, Equine Encephalitis virus, MPOX, in addition to this ongoing Covid wave.

In terms of primary care relevance with the mosquito borne illnesses, reducing or avoiding bites is the way to go.

For MPOX, I thought Katelyn Jetelina did her usual excellent summary. Unless you are in a higher risk group based on behaviors, there is not much to do differently as of now.

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Conclusion

As it is becoming a little Covidlandia tradition, I asked Claude.ai to: “summarize this article using bullet points, written in the style of an 8th grade teacher on the first day back to school.” Claude did a pretty good job, although I had to tweak a few areas:

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Alright class, welcome back! Today we're going to talk about some important health stuff that's been going on. Let's break it down into easy-to-understand points:

• COVID-19 is still around, kids! About 1 in 35 people in America might have it right now. That's a lot!

• Good news though - the numbers are starting to go down. Yay!

• There are new COVID shots available. They're designed to fight the latest versions of the virus.

• Scientists say these new shots can help protect us. I got mine yesterday!

• You can get free COVID tests soon. It's good to have some at home, just in case.

• Some people are being super careful about COVID, while others aren't worried at all. It can be awkward sometimes!

• Paxlovid (a medicine for COVID) is still working well, especially if you take it early when you get sick.

• Did you know? A weight loss medicine called Wegovy might help people not get as sick from COVID.

• Vaccines have saved lots of lives in Europe - like, millions of lives!

• Long COVID is still a big deal. It can make people feel tired and have trouble breathing for a long time after they get better.

• At the Olympics, some athletes got COVID but still competed. That's pretty rough!

• Remember, it's not just COVID we need to watch out for. There are other illnesses too, like West Nile virus and MPOX. Mosquito protection is good, and we will keep following the rest.

• The most important thing? Stay informed, be kind to each other, and do what you can to stay healthy! Let’s make this a great start to the year!

Now, who wants to share something fun they did over the summer break?

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Thanks for your patience and diligence and support as I share this latest installment of the Covidlandia series. It was another bear, but hopefully the kind of bear you like to wrestle with. This past month or two on Examined have been kind of Covid heavy, so I’ll aim to change lanes a little this month.

Take good care, spread the word, and forward at will.