September in Covidlandia

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, August, and now September. Only 3 more to go after this for 2024!

The Examined Artist-in-Residence composing this month’s postcard from Covidlandia (which may or may not have doubled as a school assignment). It awaits the stalwart reader at the finish line of this post.

Current Covid Trends

Rates are improving for most of the United States, but I am still seeing and treating Covid cases on a daily basis in my practice, which is not great. The CDC reported that more than 1,000 Americans died of Covid-19 each week in August, and these numbers are certainly an undercount. September was full of back to school spread, and it shows in this graph from the Pandemic Mitigation Collaborative shared below. An estimated 1 out of every 71 people is infectious with Covid right now. And based on their forecasting and comparisons to previous October/November trends, it looks like we will see another week or two of improvement before rates might start climbing again towards November:

My cards: I received the updated Covid shot like I said I would on 8/31/2024, consistent with CDC recommendations. Since then, for social reasons, I’ve forgone wearing a mask at a bat mitzvah, back to school night, several school tours, a high school fair, a house party, and a couple kid sleepovers. I used some azelastine nasal spray because I also have fall allergies, and maybe it helped reduce transmission along with my updated shot. Despite the above exposures to probably a thousand people, no Covid yet. I wore a KN95 to the Les Míserables show at the Philly Academy of Music, and I keep wearing my N95 at work (where I’ve also seen Covid + infections and one case of influenza B actually).

This edition is about a 15 minute read. Let’s go!

Certain intuitively higher risk activities shown to correlate with higher Covid transmission risk

A case-control study in France spanning October 2020 to October 2022 found that certain spaces, including open-space offices, long-distance trains, and nightclubs, were associated with a higher risk of COVID-19 infection. The study, published in BMC Public Health, identified common characteristics of high-risk settings: indoor spaces with poor air renewal, close and numerous contacts, often without masks, sometimes involving singing or shouting, and lasting more than a few minutes. The researchers recommend improving air renewal and filtration in these settings to reduce transmission risk and potentially benefit long-term population health.

I would add that airplanes are high risk situations. I proved that to myself with that popular post I did a while back.

It’s a no brainer for me to wear a mask in many situations like those above. But I’ve let my guard down when the social penalty for doing so matters to me. I’m guessing many of you do the same, or don’t bother with a mask at all. But I never judge anyone for wearing a mask. I freaking salute them because it takes bravery these days. Read on.

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Anecdote of the week

60 year old female. Saw me on day three of sore throat, malaise, headache, body aches. Three tests negative for Covid. I recommended treatment with Paxlovid anyway, as she was with three other family member who all tested positive for Covid a couple days before the start of her own illness.

The next day she confirmed that her test finally turned positive (day 4 of symptoms). Self-evident lessons here. Nonetheless a review of Covid-19 testing basics is really important. I will try to do a post about this soon, as I think it’s really good to recall that rapid antigen tests are not perfect. I said much the same in an interview for The Philadephia Inquirer about 3 years ago. For those at higher risk who might want treatment with an antiviral, it’s a good idea to know the context of the incipient illness and to also consider more accurate PCR/NAAT testing like most urgent care centers can send out. You have to ask these days.

Let me know YLE ;)

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Step right up and get your 4 free Covid tests

Right here.

I ordered mine already, as we’ve already paid for them with tax dollars and I find them useful. We use Covid tests whenever we think we have “a cold.” Though not perfect, this gives us treatment options and would compel us to stay home if positive to protect others.

Early antiviral treatment drops viral loads, and is associated with a higher efficacy against severe disease and long Covid prevention. This is still my plan.

And our “old Covid tests” sitting in the basement might still be fine despite having “expired” recently. Here’s that list of extended expiration dates.

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Nasal saline drops work in kids, and we can assume in adults, too

A randomized controlled trial presented at the European Respiratory Society Congress found that saline nasal drops can reduce the duration of the common cold in children by 2 days compared to usual care. The study, which included 407 children up to 6 years old, showed that those using saline drops experienced cold symptoms for an average of 6 days, compared to 8 days for those receiving usual care. Additionally, the use of saline drops was associated with a lower rate of household transmission, with fewer family members catching colds in households where children used the drops.

I tend to think of saline sprays and rinses primarily as wash out agents, but I found this quote fascinating, and perhaps why sprays often work as well as rinses:

Salt is made up of sodium and chloride. Chloride is used by the cells lining the nose and windpipes to produce hypochlorous acid within cells, which they use to defend against virus infection. By giving extra chloride to the lining cells this helps the cells produce more hypochlorous acid, which helps suppress viral replication, reducing the length of the virus infection, and therefore the duration of symptoms.

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Proof of concept with future nasal vaccines to prevent Covid infections?

Many people, including

Eric Topol

, have been clamoring for nasal vaccines against Covid. The hope is that better, primed immunity against SAR CoV-2 viruses at the respiratory ports of entry will help prevent infection better than shots in arms.

So here is a summary of the key points from a newly published study in the Journal of Clinical Investigation, including infection risk reductions gained from one such candidate nasal vaccine against Covid. This study was performed in China, right as the government opened society again and Covid ripped through on a major scale for the first time.

-The study evaluated the safety and immunogenicity of an intranasal COVID-19 vaccine (Ad5-S-Omicron) in 128 healthcare workers who had previously received 2-3 doses of inactivated vaccines.

- Key findings on immunogenicity:

• After one dose, nasal spike-specific secretory IgA (sIgA) increased 4.5-fold on average against 10 SARS-CoV-2 variants.

• After two doses, nasal sIgA dramatically increased 51.5-fold on average.

• The vaccine also induced modest increases in serum neutralizing antibodies.

- On infection risk reduction, because this is what we are really hoping for:

• 57.3% of participants who only received one dose were infected with Omicron BA.5 between days 15-28 after vaccination.

• Among 31 participants who received two doses, only 2 reported infection within 3 days after the second dose.

• The remaining 29 two-dose participants reported no symptomatic infections for 3 months following vaccination, during a period when community infection rates surged to over 85%.

• Analysis of nasal samples confirmed that two-dose participants likely remained uninfected including asymptomatic infections for those 3 months.

The authors conclude the dramatic induction of nasal sIgA after two intranasal doses likely contributed significantly to protection against Omicron infection, though they note limitations in the study design for assessing efficacy.

The 29 subjects that made it through the bottleneck of Covid surging in China to receive the second dose could absolutely be “unique” in risk avoidance behaviors or immunity, making the protective effect look better than it really is.

However, I am optimistic that even with the collective hybrid immunity in the nasal mucosa of most people already, giving a boost there will hopefully reduce infections for a while (3+ months please!). Zero of those 29 is still impressive in the context of a surge that caught 85% of the Chinese population.

Also, hopefully priming the defenses at the front door will lead to lower viral loads and faster clearance of coronaviruses, both of which are associated with less collateral damage and long covid.

I think these will be net positives if not game changers, and such platforms will need to be nimble to keep up with mutations in spike proteins. Others are surely targeting other parts of coronaviruses that don’t mutate as fast as spike. Right?

A great deep dive on this from Ed Nirenberg can be read here. Fingers crossed, and also tapping impatiently. It’s year 5. Let’s go.

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Long Covid answers and education

Here is a good collection of resource sheets created by a site called Long Covid Justice. Some of the ideas may seem over the top for people who have moved beyond caution with Covid. But for others who are still playing the game of reducing risks, or have been affected by long Covid already, there’s good stuff here. I’ll share one reminder about exercise after Covid illness. We should return to activity slowly and listen to our bodies. More exertion than we are ready for can actually damage muscles and mitochondria.

Take it easy for at least 6 weeks after COVID-19, if your life circumstances allow. Gradually introduce lighter forms of exercise like yoga or walking - not too much at once. Breathwork, stretching, and bodywork can be helpful before restarting exercise. Stretching while lying down may be easier than upright activities.

There is a resource sheet about “how to avoid getting Covid now.” It includes a link to a Slate.com article about nasal sprays. Frankly, that article I posted here on nasal sprays is much better.

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Outlier study finds vaccines did not help prevent long Covid

A quick note about a study that reported no reduction in long Covid rates from vaccinations. I think this study is flawed in that it mined medical records for “long Covid” diagnoses as its main source of data.

Diagnosing long Covid is tough. Symptoms overlap with many other conditions, may develop months after infections (and many people are not testing or are asymptomatic), and there are no definitive blood tests in primary care to prove long Covid yet. It’s an outlier study, and I agree with this:

Ziyad Al-Aly, MD, chief of research and development at the VA St. Louis Health Care System and a clinical epidemiologist at Washington University… just published a review of evidence showing that vaccination reduces the risk of long COVID. While the effect size varies by 15% to 70%, there is an estimated average reduction of 40% to 50%, almost universally.

He said he found Swift’s study surprising and said it likely suffers from one main confounding factor: The type of patient who seeks out a long-COVID diagnosis likely uses healthcare and is vaccinated.

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I already told you that I rolled my sleeve up. It’s your choice, and I know some people get really sick with shots and have other considerations. But in case you missed this post and want to compare notes:

I used this graph with a patient yesterday who thought “the new Covid shots are way behind the current variants.” Not really in my opinion. Look at KP.2 above which is the template for the mRNA shots, or even JN.1 for Novavax. Then find KP.3.1.1 which is still making the rounds. Not that far off the tree?

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Long Covid is a real thing in kids, unfortunately

No one wants to admit this, as we want our kids to have a normal-ish childhood. But we can still take some measures to reduce risks when we can. For example, we decided to keep our daughter up to date with vaccines.

A new long-term prospective study published in eClinical Medicine/The Lancet followed 1,319 children for up to 3 years after SARS-CoV-2 infection, finding that 23.2% met criteria for Long Covid at 3 months, 7.1% at two years, and with some still experiencing symptoms at 3 years. The study identified risk factors for Long Covid, including older age, comorbidities, infection with pre-Omicron variants, and female sex. Vaccination was associated with a significantly lower risk of Long Covid, particularly in adolescents. The researchers also observed that 1.1% of children developed new-onset autoimmune disorders, with a significant association found between the original SARS-CoV-2 variant and autoimmune disease development.

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COVID vaccines saved up to 2.6 million lives in Latin America, Caribbean

Building on the European study last month that showed millions of lives saved by the vaccines, we have this modeling study out of Yale and the Pan American Health Organization: up to 2.6 million more lives spared.

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Mask bans are very un-American. Are they pro-fascist?

America aspires to be the land of the free, where government does not claim dominion over our bodies, our family privacies, and our freedoms to protect and express ourselves.

And yet we teeter on the brink of fascism in many ways. Women’s bodies. Disenfranchisement. Propaganda. Anti-intellectualism. Division. Xenophobia.

Here’s a small example among the many. There is a bipartisan groupthink that scorns the mask as an inconvenient reminder of this truth - Covid is still a problem. And now we have a radical partisan attack upon the right to wear one, in flagrant conflict with science and public health. If we don’t want to wear a mask, fine. But live and let live.

An excellent primer on this subject was published by The Sick Times:

• Mainstream media coverage of mask bans has given space for politicians’ false claims that masks are associated with wrong-doing, like crime and antisemitism, while overlooking that bans are, in many ways, an effort to suppress the reality of Covid-19.

• There are 21 states and numerous municipalities with laws against masks or disguises on the books.

• Both Republicans and Democrats are pushing more severe mask bans than ever before in history. Democrats are more likely to give lip service to health needs without offering meaningful protections.

• Masks can and will be criminalized by police regardless of the language of the law, as arrest trends follow social trends. Police are also permitted by the Supreme Court to make mistakes in enforcing laws.

Even in New Jersey (where I practice) a Republican state senator recently introduced a bill to ban masks. Of course it’s a bad idea, with lots of potential for cruelty. The Star-Ledger then published a good editorial calling such bans dumb and dangerous. A few choice quotes:

…this is a superficial policy that quickly falls apart on the details, and presents a clear danger to civil liberties.

Start with this basic question: What if a troublemaker simply decides to disguise his face with large sunglasses and a hat, instead? Are we going to criminalize sunglasses and hats, too?

…this “overbroad and vague” bill “also gives law enforcement the ability to target people based on their political beliefs.”

If Republicans are trying to send a message, a more sensible way to do it would be to increase the penalties for anyone committing a crime in disguise. Criminalizing masks won’t help. As the Washington Post reported:

“The day after the North Carolina House of Representatives passed its anti-masking bill in June in response to pro-Palestinian protests at the University of North Carolina, Shari Stuart said a man confronted her for wearing a surgical mask when she walked into an auto service center in the Raleigh area to get an oil change. After she tried to explain that she has Stage 4 breast cancer and a weakened immune system, Stuart said, the man called her a ‘f---ing liberal’ and insisted masks were now illegal. He later coughed on her and said he hoped the cancer would kill her.”

That guy and his ilk are not only un-American, but something much worse.

Several underpinnings of mask bans are built upon fascist principles. From Jason Stanley’s How Fascism Works, we can see how these core elements of fascism underpin the arguments in favor of mask bans:

• delegitimize any source of resistance by characterizing it as an “other” or an “out group” to be scorned

• offer new “truths” to supplant “facts”

• divide people while undermining unity and notions of diversity

• emphasize law and order to protect citizens from “undesirable” elements, violently if needed.

Anyone regardless of political party who would take a personal and public health tool away from those who choose to deploy it, here in the land of the free, should know they are marching in step with a fascist agenda. Recall that it’s less about banning the actual mask than it is about forcing an ideology - that Covid is all good now for everyone. That scientists and intellectuals and vulnerable people present an uncomfortable reality, so let's turn on them.

He later coughed on her and said he hoped the cancer would kill her.

The red pill is the one that uncovers the unsettling, actual truth.

Keep taking it.

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I’m sick of politics

And yet we have an election in about one month. Republicans, Democrats, and everyone in between need to be clear-eyed about what is at stake. Dick Cheney is. Michelle Obama is.

Staying in my lane as a doctor looking at public health, I’m very concerned. The radical agendas and plans of politicians who infringe upon our domain force physicians of conscience to speak up. Maybe that’s what they want, to further turn their people against us. Nonetheless, an excellent post from ScienceBasedMedicine is a must read:

If you want to see the direction that the federal government will likely take if Trump becomes President again and RFK Jr. oversees the appointment of federal officials overseeing public health agencies, such as the FDA Commissioner and CDC Director, look no further than Florida, where COVID-19 contrarianism, hostility to public health, and outright antivax misinformation have taken over the Department of Health of a large state.

And here are some of Florida Surgeon General Joseph Ladapo’s partisan actions. FYI.

Many states have cynically kicked people off the voter registration rolls. Maybe you? Check and make sure you are registered here.

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Another suggestion that metformin probably helps treat Covid

A new study from researchers at the National Institutes of Health suggests that metformin, a common type 2 diabetes drug, can lower the risk of developing long Covid in diabetic patients. The study, published in Diabetes Care, analyzed electronic health records of over 75,000 adults taking metformin for type 2 diabetes and compared them to patients using other diabetes medications. While the exact mechanism is unknown, the findings indicate a mildly beneficial role of metformin in reducing chronic SARS-CoV-2 outcomes in people with diabetes, with hazard ratios showing a 13% to 21% lower rate of long Covid or death in metformin patients compared to non-metformin users.

These findings come from the ongoing RECOVER trial and build on results seen in a 2023 trial, which showed metformin cuts the risk of long Covid by 40%.

I continue to offer this to patients with Covid. Some have significant GI side effects like nausea, and either stop or continue a lower dose for the recommended two weeks. Most people tolerate metformin ok though. Hard to predict.

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Old data, but more support for boosters and long Covid prevention

This new study published in Open Forum Infectious Diseases found that healthcare personnel who received additional COVID-19 vaccine doses had a lower prevalence of symptoms 6 weeks after infection during the Omicron period.

Specifically, those with COVID-19 who had received a subsequent vaccination had 45% lower odds of experiencing symptoms at 6 weeks compared to those who hadn't received additional doses.

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20 years of extra brain aging with severe Covid

A major UK study published in Nature Medicine revealed that COVID-19 patients hospitalized over a year ago exhibited worse cognitive function, reduced brain volume, and elevated brain injury markers compared to non-hospitalized individuals, with deficits comparable to 20 years of normal aging. While the findings suggest measurable biological mechanisms for COVID-19's long-term brain impacts, researchers observed a trend towards recovery in longer-term follow-ups and are now investigating whether similar mechanisms might apply to other severe infections.

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Volunteers intentionally infected with the original virus showed declines in cognitive measurements

This study published in eClinicalMedicine/The Lancet found that participants infected with Wildtype SARS-CoV-2 in a controlled human challenge trial showed reduced cognitive performance, particularly in memory and executive function tasks, compared to uninfected participants. The cognitive deficits persisted for at least one year after infection, even in mild cases, and were detectable through objective measures despite participants not reporting subjective cognitive symptoms. The findings provide strong evidence for a causal link between SARS-CoV-2 infection and cognitive changes, supporting previous cross-sectional studies.

These volunteers were recruited in 2021, and had neither been infected nor previously vaccinated. The intentional infection aspect is questionably ethical (I agree with Dr. Daniel Griffin from TWiV on this).

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We keep rolling the dice with Covid infections and long haul symptoms

I hate this reality, and grant that we can only be so careful without missing our actual lives. But I still take prudent precautions when I can, and reduce my risk if not eliminate it over time. Covidlandia - a forgotten land between black and white, carefree and cautious, pandemic beginning and end, right?

A survey study suggests that multiple Covid infections significantly increase the risk of developing long Covid, with two infections more than doubling the risk and three or more infections nearly quadrupling it compared to a single infection. The research, based on a global survey of over 3,000 respondents, also found that reinfections raised the likelihood of severe fatigue and functional limitations. While vaccines and boosters reduced the risk of long Covid, their effectiveness diminished with subsequent infections in this survey, highlighting the importance of prevention measures and consideration of reinfections in long Covid research and clinical practice.

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Merciful conclusion

You made it! I barely did, too. Here is what we reviewed for September using bullet points:

• Covid remains an ongoing concern, with prevalence rates improving (1/71) but with a forecast for future increases perhaps towards November.

• Certain activities and spaces, such as open offices, long-distance trains, and nightclubs, are associated with higher transmission risks.

• Updated vaccines and nasal sprays show promise in reducing infection rates and symptom severity.

• Long Covid continues to be a significant issue, affecting both adults and children, with some experiencing symptoms for years.

• Mask-wearing remains a personal choice for protection, but mask bans in some areas raise concerns about civil liberties and public health.

• Ongoing research suggests potential treatments and preventive measures, such as metformin for reducing long Covid risk

• Multiple Covid infections appear to increase the risk of developing long haul syndromes, emphasizing the importance of continued precautions.

• The pandemic's impact on cognitive function and brain health is becoming clearer, with severe cases potentially causing significant long-term effects.

• As we navigate "Covidlandia" - a middle ground between pandemic start and end - balancing caution with normal life activities remains a challenge for many. I’ve let my guard down by social necessity, but not in all situations.

Take good care out there. I still try to seek beauty, truth, and connection in the world, even as I acknowledge and prepare for its risks and rewards.

A postcard from the artist in residence 👧