COVID-19 Status Update: Part 2

Long COVID, vaccine efficacy and uptake, and ways to protect yourself...

Jan 24, 2024

Alright, yesterday we covered the current state of disease spread, a hint of the awful vaccine uptake, and a refresher on how viral strains emerge. Part 2 will discuss other common questions that keep cropping up:

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First: What do we know about Long COVID?

We get asked all the time to provide an update on Long COVID (officially, post-acute sequelae of SARS-CoV-2 infection)– and we haven’t done so because we have been waiting to review updated and more scientifically-informed data (as opposed to observational and survey-based data).

Some of the key points we want to convey upfront are that: 1) yes, long COVID is real (and can be absolutely terrible for some people) but we think its prevalence may be overstated due to its nonspecific symptoms which may be conflated with other clinical conditions and 2) while SARS-CoV-2 does cause some immune dysregulation, there is no evidence that it is on par with the damage done by HIV (as many have claimed). It appears, like other illnesses that lead to post-infection sequelae (yes, we HAVE talked about this in the context of Lyme disease, as has the CDC for decades), that true prevalence of long COVID is between 5-10% of individuals who were infected with SARS-CoV-2.

We are going to do a separate Substack article on Long COVID pathology– stay tuned for that! But here’s a quick update on some new research…

A recent study published in Science compared the blood of patients with confirmed SARS-CoV-2 infection with that of uninfected controls. Researchers found that patients experiencing Long COVID exhibited changes to blood serum proteins indicating activation of the immune system’s complement cascade, altered coagulation, and tissue injury. At the cellular level, Long Covid was linked to aggregates comprising monocytes and platelets. These findings provide a resource of potential biomarkers for diagnosis and may inform directions for treatments– but we aren’t there yet.

What else do we know?

Another recent study compared hospitalized COVID patients to healthy controls to help better understand Long COVID by assessing cognitive, serum biomarker, and neuroimaging findings. Researchers found that COVID-19 patients were more likely to have cognitive deficits associated with elevated brain injury markers and reduced anterior cingulate cortex volume (involved in decision-making). They found that more severe illness, mental health problems after COVID-19, and past brain problems were linked to worse cognitive issues. The study suggests that COVID-19 can damage the brain (or at least vasculature), and immune system responses may be involved. Treatment with corticosteroids during the acute phase appeared protective against cognitive deficits, though more research is needed to both understand protective effects of steroid treatment, treatments. Together, these findings provide some evidence to support the notion that brain injury in moderate to severe COVID-19 is immune-mediated, and may guide the development of therapeutic strategies. We just aren’t quite there yet.

Does vaccination help prevent long COVID?

Yes, the research indicates that vaccination does reduce the risk of long COVID.

A study in The Lancet (Respiratory Medicine) aimed to evaluate the overall impact of vaccination to prevent long COVID symptoms and assess comparative effectiveness across different vaccine types (Pfizer versus Astrazeneca). Researchers analyzed data from over 10 million vaccinated and 10 million unvaccinated individuals in the UK, Spain, and Estonia.

They found that vaccination against COVID-19 consistently reduced the risk of long COVID symptoms (40% reduction with the mRNA vaccines versus no vaccines– about 15% better than the Astrazeneca vaccine), which highlights the importance of vaccination to prevent persistent COVID-19 symptoms, particularly in adults. Of note, the protection against Long COVID was especially notable in people who were not considered high-risk.

What about COVID-19 vaccine status?

Well, we are super disappointed to report that vaccine uptake has been abysmal.

As of January 6, 2024, 21.4% of adults reported having received an updated 2023-24 COVID-19 vaccine since September 14, 2023. As of December 30, 2023, 8.0% of children were reported to be up to date with the 2023-24 COVID-19 vaccine.

Reminder: Anyone 6 months and older can (and should) get the new COVID-19 vaccine.

It does not matter how many doses you’ve received previously.

The new vaccine is effective against currently circulating strains. We have heard people say that they can’t find a vaccine local to them (this is very upsetting– and it’s largely due to the fact that because we are no longer in a public health state of emergency, funding for vaccines has changed– and many pharmacies and doctor’s offices are scared to order vaccines only to have them go unused (aka wasted money).

Some tips:

Check vaccines.gov
Contact your local department of health; they may run vaccine clinics or have suggestions for other community health organizations offering vaccines
Ask your pediatrician for recommendations

For those who do not have insurance that covers COVID-19 vaccines (or lack coverage altogether): CDC’s Bridge Access Program provides free COVID-19 vaccines to adults without health insurance and adults whose insurance does not cover all COVID-19 vaccine costs.

Which vaccine should you get?

We have not seen any compelling data showing clinically-relevant differences in effectiveness for the mRNA (Pfizer-BioNTech and Moderna) versus Novavax vaccines. We did a post on the Novavax vaccines and the protein subunit technology used if you want to read up on it! The short answer is: get whichever vaccine you can access the easiest and/or the fastest.

If the COVID-19 vaccines are so effective, why do I need to keep getting more of them? This is a very valid question; it’s one that requires deeper discussion of immunological complexities to properly address but let’s simplify for the time being:

For one, viruses mutate—including SARS-CoV-2 which is the virus that causes COVID-19. Every single time the virus is transmitted from person to person, it has an opportunity to mutate. This leads to the emergence of new strains which are less effectively targeted by older vaccine formulations.

Another factor is that immunity (the protection we get from both vaccines AND natural infection) decreases over time. This is quite common for respiratory viruses (like the flu!) because we don’t fully harness a particular arm of immunity (called the mucosal immune response) to the maximum extent.

So, for now, our best option is to get a once-annual shot that is updated to match the viral strains and variants that are currently circulating. Scientists are working on different technologies and a universal vaccine which could mean that we don’t need a COVID-19 shot every year in the future—but this is what we currently have available to us. The vaccines are highly effective at protecting us from getting severely sick or dying from COVID-19. They were not designed to prevent transmission (although the vaccines did effectively prevent transmission against older strains of the virus, that is no longer the case). We also know that vaccines effectively reduce the likelihood and severity of long COVID.

Testing

It’s important to know if you have COVID-19 versus the flu versus something that’s not viral at all — like strep throat — because they have different treatments! Yes, the current rapid tests are effective at detecting the JN.1 variant (there are no data to suggest otherwise at this time).

Remember that you can order your no-cost tests from the federal government here. Every home in the U.S. is eligible to order an additional 4 free at-⁠home tests beginning November 20. If you did not order tests this fall, you may place two orders for a total of 8 tests. Your order of COVID tests is completely free – you won’t even pay for shipping. Stock up now, trust us– you won’t regret it!

Should we be masking?

This is a tough question to answer because we all have different risk thresholds. If you are high risk, live with someone who is high risk, or just prefer to mask– it’s not a bad idea to mask when indoors in crowded settings with poor ventilation. It is never a bad idea to mask in high-risk settings like medical offices where you know you’ll encounter sick people.

If you’re in an acute medical care setting like an emergency room, urgent care, primary care office, etc.—you know that you are likely surrounded by people who are actively sick and possibly contagious (you might be, too).

Even in other non-acute medical settings that might seem lower risk in terms of infectious disease, you should consider that many people are battling chronic, often “invisible” illnesses that put them at high risk for severe illness. And we aren’t just talking about COVID-19! Masks protect us and those around us from a VARIETY of communicable diseases that can be spread via respiratory or droplet transmission.

The costs are low and the benefits are very high. It’s not like we are saying you need to mask up 24/7. This is a simple step to protect ourselves and those around us for a brief period of time when we are in high-risk settings.

(This also applies to clinicians and medical providers who encounter many sick people on a daily basis. Protect yourselves and others, and set an example for your patients!)

What to do if we are sick with COVID-19?

Most of us know the drill by now– stay home, sleep, hydrate, and do your best to isolate from other members of your household to avoid infecting them. You may also consider taking Paxlovid, especially if you are high risk, which is an effective anti-viral that has been shown to reduce disease severity and duration of illness. But when is it safe to return to work (masked and unmasked)?

Per the CDC, If you test positive for COVID-19, stay home for at least 5 days and isolate from others in your home. You may end isolation after day 5 if You are fever-free for 24 hours (without the use of fever-reducing medication). You should isolate through day 10 if you had

Moderate illness (you experienced shortness of breath or had difficulty breathing), severe illness (you were hospitalized), or have a weakened immune system.

But certain places, like the State of California, have recently adjusted their COVID-19 recommendations. The State just announced that they have moved away from five days of isolation and instead focus on clinical symptoms to determine when to end isolation. The new guidance reads as follows:

Stay home if you have COVID-19 symptoms, until you have not had a fever for 24 hours without using fever reducing medication AND other COVID-19 symptoms are mild and improving.
- If you do not have symptoms, you should follow the recommendations below to reduce exposure to others.
Mask when you are around other people indoors for the 10 days* after you become sick or test positive (if no symptoms). You may remove your mask sooner than 10 days if you have two sequential negative tests at least one day apart. Day 0 is symptom onset date or positive test date.

Our two cents? If you are recovering from COVID-19, we would recommend masking until at least day 5 (ideally day 7) because you may still be shedding virus. The soonest we’d recommend not masking is day 5 with a negative test result. With a positive test, we probably wouldn’t stop masking until at least day 7 (but day 10 would be the safest bet).

We are able to prevent the most severe outcomes due to COVID-19 with vaccines and treatment options, but COVID-19 is still around, and unfortunately, complacency and low vaccine uptake has led to people getting sick when it could have been avoided.

That’s it for today! But if you missed it, our newest podcast episode just dropped on menopause with

Dr. Jen Gunter

. Watch it here (and subscribe to our YouTube):