Coronavirus updates December 2021

[missy]

Opinion: The Supreme Court must uphold Biden’s vaccine mandates — and fast​

The Supreme Court is set to scrutinize coronavirus vaccine mandates in the coming weeks. (Ted S. Warren/AP)
By Lawrence O. Gostin
,
Jeffrey E. Harris
and
Dorit Rubinstein Reiss




Lawrence O. Gostin, a professor at Georgetown University and director of the World Health Organization Collaborating Center on National and Global Health Law, is author of “Global Health Security: A Blueprint for the Future.” Jeffrey E. Harris is emeritus professor at the Massachusetts Institute of Technology and practicing physician at Eisner Health, a community health center in Los Angeles. Dorit Rubinstein Reiss is a law professor at University of California, Hastings College of the Law.


"
President Biden’s emergency covid-19 mandates have faced an avalanche of legal challenges. Two of those mandates — the Occupational Safety and Health Administration’s rule that businesses with 100 or more employees must require workers to be fully vaccinated or regularly tested and the Centers for Medicare and Medicaid Services’ regulation requiring vaccinations for staff at health-care facilities — will soon face scrutiny from the Supreme Court.
The Supreme Court needs to uphold the president’s mandates without delay. Not doing so would be an affront to public health and the law.


Lower-court rulings that blocked the rules from taking effect were fundamentally flawed. (The president’s executive order requiring federal contractors to have a fully vaccinated workforce is currently blocked by courts in Kentucky and Georgia, but is not yet before the Supreme Court). They disregarded the broad scientific consensus that covid-19 poses a major public health threat requiring a strong emergency response; indeed, the public health emergency has only become more acute in recent weeks. The omicron variant is rising exponentially across the nation, pushing the hospital system beyond its capacity. More than 1,400 Americans are dying every dayfrom covid-19. The justices need to weigh this grim reality.
A threshold issue is whether covid-19 is a public health emergency that warrants bypassing the usual cumbersome regulatory process. For the employer mandate, OSHA issued an emergency standard which can be implemented rapidly. For the rule involving health-care workers, CMS waived the normal period for taking public comment into consideration before issuing final regulations, a process that can take months if not years. Both had good reason for acting swiftly.

OSHA conservatively estimated its new rule would prevent more than 6,500 deaths and 250,000 hospitalizations. CMS established an impressive record showing the unique vulnerability of Medicare and Medicaid recipients, who are older, disabled, chronically ill or have complex health-care needs. The rule can save hundreds of lives each month. The science is also clear that the vaccine is the best way to ameliorate risks of covid-19 infections, hospitalizations and deaths. Delaying the implementation of the rules would cost lives.


At the core of these cases is the claim that Congress has not clearly authorized OSHA and CMS to safeguard workers. That’s incorrect. The Occupational Safety and Health Act empowers OSHA to mitigate “grave” workplace dangers through emergency measures. OSHA has required the only effective tools known to science: vaccines, testing and masks. Vaccination is the best tool, but OSHA allows employees to opt-out simply by testing weekly and masking. It’s hardly an overreach. In fact, regulating biological hazards is among OSHA’s primary responsibilities. The agency has a long history of regulating protections against airborne and bloodborne pathogens.
Likewise, when Congress established the Medicare and Medicaid programs, it granted the secretary of health and human services authority to require facilities to meet requirements deemed “necessary in the interest of the health and safety.” There are ample reasons to support the conclusion that vaccinations are necessary for the safe operation of participating facilities: the vulnerability of residents, the need for a healthy workforce and the unique effectiveness of vaccines.
There are good reasons Congress has chosen to delegate broad regulatory powers to agencies. Congress cannot foresee the broad range of risks Americans will face. Nor does Congress have the expertise or access to rapidly changing and complex scientific information needed to make wise regulatory decisions. Career agency professionals have the expertise — and can act more quickly with more flexibility — than the legislative process allows. The need to act rapidly is especially important in a health emergency. If the high court were to curb federal public health powers now, it could prove ruinous when the next crisis strikes.


The Supreme Court has a long history of upholding vaccination mandates, beginning with its seminal 1905 decision upholding smallpox vaccination and continuing with its 1944 ruling on the lawfulness of childhood vaccinations for school entry. Recently, the Supreme Court let stand a New York coronavirus vaccine mandate for health-care workers, even though it provided no religious exemption.
But these are all municipal or state mandates, and the court has been far more reticent to uphold federal health powers — for example, striking down the Centers for Disease Control and Prevention’s covid-19 eviction moratorium. The CDC arguably overreached with the moratorium, but regulating workplace safety is core to OSHA’s mission, as is regulating health-care safety to CMS.
A dire emergency is not the time to overturn decades of jurisprudence empowering federal agencies to act in the public interest. Justices should defer to the judgment of agency professionals, which represents the unquestioned scientific consensus. Vaccines offer the best, possibly the only, way to curtail the covid-19 pandemic.

"

 

[missy]

From the NYT Dec 30th 2021​ ​ Changes and confusion​ ​

As we approach the third year of the pandemic, the coronavirus continues to make life difficult — and confusing. Official guidance on masks, testing and isolation change as new variants emerge, and a stream of case numbers turns us into armchair epidemiologists, trying to figure out how risky it is to attend a New Year’s Eve party.​

If the past few weeks have left you dizzy, you’re not alone. In today’s newsletter we’ll explain some recent developments and take stock as we head into 2022.​

New isolation rules​ ​

The C.D.C. this week shortened its recommended isolation period, saying that people who are infected can re-enter society after five days if they don’t have symptoms or if their symptoms are resolving. The guidance adds that people should wear a mask for five days after that.​

The change came about, officials said, because studies have found that a majority of transmission happens in the first five days of an infection. It also allows companies to bring back workers in half the time.​

Delta Air Lines, which had urged the C.D.C. to adopt the change, welcomed the news, as did officials in the food and retail industries. In New York City, a vital subway line shut down yesterday because so many workers were out sick. Shops and restaurants have temporarily closed across Europe.​

Dr. Ashish Jha called the new guidance “reasonable,” as long as people follow the rule that they leave isolation only if they are asymptomatic. But Jha added that he would have required a negative rapid test before leaving isolation.​

Many public health experts had a harsher reaction to the new rules, particularly the decision to omit testing. Angela Rasmussen, a virologist at the University of Saskatchewan, called it “reckless and, frankly, stupid.”​

Dr. Rochelle Walensky, the C.D.C. director, told CNN that the guidance “had a lot to do with what we thought people would be able to tolerate.” She estimated that less than a third of people who should have isolated in the past had done so; the new rules, she said, were meant to encourage people to stay in when they were “maximally infectious.”​

Experts also noted that the guidelines make no distinction between vaccinated and unvaccinated people who test positive, despite the unvaccinated facing far greater risks.​

“The C.D.C. should develop further guidelines, right now, that allow for those who are vaccinated and boostered to leave isolation as soon as possible after they have gotten negative results repeatedly with antigen tests,” Dr. Aaron E. Carroll, the chief health officer for Indiana University, wrote in The Times. And, he added, the Biden administration should do “everything possible to make such antigen tests freely and easily available.”​

Severe cases​ ​

It’s too early to be sure of Omicron’s effect on hospitalizations and deaths. But health officials say the early data offers some cautiously positive signs.​

Walensky said yesterday that cases had increased by around 60 percent over the past week and hospitalizations had risen by 14 percent. While hospitalizations tend to lag cases, she noted, the pattern is similar to countries that have had the variant for longer, like South Africa and Britain.​

Take the two states below as an example. New York has been one of the hardest-hit states in the current wave, and Florida was hit hard this summer by Delta. In each, hospitalizations haven’t yet reached the levels of last winter’s peaks, despite cases rising past that mark. (Look up your state here.)​

Source: New York Times database​

“The pattern and disparity between cases and hospitalizations strongly suggest that there will be a lower hospitalization-to-case ratio when the situation becomes more clear,” Dr. Anthony Fauci said yesterday.​

It’s not clear that Omicron’s severity is the main cause of the split between cases and hospitalizations, though, as a year’s worth of vaccinations and infections have strengthened the country’s resistance to the virus.​

Omicron and Delta​ ​

Over the past few weeks, we’ve been talking a lot about Omicron, which is the dominant variant in the U.S. and many other countries. But Delta, the variant that came to prominence in the summer, is still here.​

South African scientists are hoping that there’s some good news: People who have recovered from an infection with Omicron may be able to fend off Delta, according to a small early study. (The reverse is most likely not true: Delta antibodies seem to offer little protection against Omicron.)​

If the theory holds, Omicron may eventually overwhelm Delta, Carl Zimmer explained in The Times. And if Omicron is indeed less severe, its takeover could mean that fewer people get seriously ill or die.​

But that doesn’t mean that Omicron will be the only variant for years to come, Carl wrote: “Once people gain immunity to Omicron, natural selection may favor mutations that produce a new variant that can evade that immunity.”​

Something else to know about Omicron versus earlier variants: The incubation period seems to be shorter. It may take three days for people to develop symptoms, become contagious and test positive, compared with four to six days with Delta.​

New Year’s Eve​ ​

All of this could have you asking whether to gather with friends or family members for New Year’s Eve tomorrow. Many public health experts agree that you can celebrate with your favorite people as long as you’re taking precautions.​

To help you make a decision and gauge the level of risk, The Times has this quiz.​

More on the virus:​

Health officials are considering redefining what it means to be “fully vaccinated.” Most people don’t report the results of their home rapid tests, raising questions about the accuracy of public case counts. J.&J.’s booster shot offered strong protection against Omicron, a clinical trial found.

 

[missy]

Coronavirus Can Spread to Heart, Brain Days After Infection​

Carolyn Crist

"

The coronavirus that causes COVID-19 can spread to the heart and brain within days of infection and can survive for months in organs, according to a new study by the National Institutes of Health.
The virus can spread to almost every organ system in the body, which could contribute to the ongoing symptoms seen in "long COVID" patients, the study authors wrote. The study is considered one of the most comprehensive reviews of how the virus replicates in human cells and persists in the human body. It is under review for publication in the journal Nature.
"This is remarkably important work," Ziyad Al-Aly, MD, director of the Clinical Epidemiology Center at the Veterans Affairs St. Louis Health Care System in Missouri, told Bloomberg News. Al-Aly wasn't involved with this study but has researched the long-term effects of COVID-19.

"For a long time now, we have been scratching our heads and asking why long COVID seems to affect so many organ systems," he said. "This paper sheds some light and may help explain why long COVID can occur even in people who had mild or asymptomatic acute disease."

The NIH researchers sampled and analyzed tissues from autopsies on 44 patients who died after contracting the coronavirus during the first year of the pandemic. They found persistent virus particles in multiple parts of the body, including the heart and brain, for as long as 230 days after symptoms began. This could represent infection with defective virus particles, they said, which has also been seen in persistent infections among measles patients.
"We don't yet know what burden of chronic illness will result in years to come," Raina MacIntyre, PhD, a professor of global biosecurity at the University of New South Wales, told Bloomberg News.
"Will we see young-onset cardiac failure in survivors or early-onset dementia?" she said. "These are unanswered questions which call for a precautionary public health approach to mitigation of the spread of this virus."
Unlike other COVID-19 autopsy research, the NIH team had a more comprehensive post-mortem tissue collection process, which typically occurred within a day of the patient's death, Bloomberg News reported. The researchers also used a variety of ways to preserve tissue to figure out viral levels. They were able to grow the virus collected from several tissues, including the heart, lungs, small intestine, and adrenal glands.
"Our results collectively show that while the highest burden of SARS-CoV-2 is in the airways and lung, the virus can disseminate early during infection and infect cells throughout the entire body, including widely throughout the brain," the study authors wrote.

Sources​

Research Square: "SARS-CoV-2 infection and persistence throughout the human body and brain."


"

 

[missy]

CDC Lowers Omicron Estimate of Coronavirus Variants in US to 58.6%​

By Reuters Staff

The Omicron variant was estimated to be 58.6% of the coronavirus variants circulating in the United States as of Dec. 25, according to data from the U.S. Centers for Disease Control and Prevention (CDC) on Tuesday.
The agency also revised down the Omicron proportion of cases for the week ending Dec. 18 to 22% from 73%, citing additional data and the rapid spread of the variant that in part caused the discrepancy.
"We had more data come in from that timeframe and there was a reduced proportion of Omicron," a CDC spokesperson said. "It’s important to note that we’re still seeing a steady increase in the proportion of Omicron."
The fast-spreading variant was first detected in southern Africa and Hong Kong in November, with the first known case in the United States identified on Dec. 1 in a fully vaccinated person who had traveled to South Africa.

Since then, the strain has rapidly spread across the world and driven a surge in U.S. infections, causing widespread flight cancellations and dashing hopes for a more normal holiday season.

The Delta variant, which had been the dominant strain in the past few months, accounts for 41.1% of all U.S. COVID-19 cases as of Dec. 25, the public health agency's data showed.
Former U.S. Food and Drug Administration Commissioner Scott Gottlieb said on Twitter that if the CDC's new estimate of Omicron prevalence was precise, then it suggests that a good portion of the current hospitalizations may still be driven by Delta infections.
The agency said the data includes modeled projection that may differ from weighted estimates generated at later dates.


Reuters Health Information © 2021

 

[dk168]

My plan for NYE now is to spend at home with the pets to avoid unnecessary socialising, as I cannot afford to be ill or self-isolate, having planned for a site visit for an important business meeting.

I shall welcome the New Year with a large mug of boozy hot chocolate!

DK

 

[missy]

From the NEJM December 30th, 2021​

​

"​

​

Third BNT162b2 Vaccination Neutralization of SARS-CoV-2 Omicron Infection​

TO THE EDITOR:​

On November 26, 2021, the World Health Organization (WHO) named the B.1.1.529 (omicron) variant of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), first detected in South Africa, as a variant of concern.1 By November 29, 2021, three days after the announcement by the WHO, cases of infection with the omicron variant had already been detected in many other countries.
Whether the BNT162b2 vaccine (Pfizer–BioNTech), which was previously shown to have 95% efficacy against coronavirus disease 2019 (Covid-19),2,3 will effectively neutralize infection with the omicron variant is unclear. We compared neutralization of omicron-infected cells in serum samples obtained from participants who had received two doses of vaccine with neutralization in samples obtained from participants who had received three doses.
Microneutralization assays with wild-type virus and B.1.351 (beta), B.1.617.2 (delta), and omicron variant isolates were performed with the use of serum samples obtained from two groups of 20 health care workers. One group comprised participants who had received two doses of the BNT162b2 vaccine (mean, 165.6 days since receipt of the second dose), and the second group comprised those who had received three vaccine doses (mean, 25 days since receipt of the third dose) (Table S1 in the Supplementary Appendix, available with the full text of this letter at NEJM.org). Significance was assessed with the use of a Wilcoxon matched-pairs signed-rank test.
Figure 1.

Neutralization Efficiency against Wild-Type Virus and the Beta, Delta, and Omicron Variants of Concern.
Receipt of three vaccine doses led to better neutralization of the wild-type virus and the three variants than receipt of two vaccine doses (Figure 1). The geometric mean titers of the wild-type virus and the beta, delta, and omicron variants were 16.56, 1.27, 8.00, and 1.11, respectively, after receipt of the second vaccine dose and 891.4, 152.2, 430.5, and 107.6, respectively, after receipt of the third dose. A significantly lower neutralization efficiency of the BNT162b2 vaccine against all the tested variants of concern (beta, delta, and omicron) than against the wild-type virus was observed in samples obtained from participants who had received two doses than in those obtained from participants who had received three doses (Figure 1B and 1D). The lower neutralization efficiency against the beta and omicron variants than against the wild-type virus was similar in samples obtained from participants who had received two doses and in those obtained from participants who had received three doses. The third dose of the BNT162b2 vaccine efficiently neutralized infection with the omicron variant (geometric mean titer, 1.11 after the second dose vs. 107.6 after the third dose) (Figure 1A and 1C).
We analyzed the neutralization efficiency of the BNT162b2 vaccine against wild-type SARS-CoV-2 and the beta, delta, and omicron variants of concern. Limitations of the study include the small cohort tested and the fact that the test was only an in vitro assay. Nevertheless, we found low neutralization efficiency with two doses of the BNT162b2 vaccine against the wild-type virus and the delta variant, assessed more than 5 months after receipt of the second dose, and no neutralization efficiency against the omicron variant. The importance of a third vaccine dose is clear, owing to the higher neutralization efficiency (by a factor of 100) against the omicron variant after the third dose than after the second dose; however, even with three vaccine doses, neutralization against the omicron variant was lower (by a factor of 4) than that against the delta variant. The durability of the effect of the third dose of vaccine against Covid-19 is yet to be determined.
Ital Nemet, Ph.D.
Limor Kliker, M.Sc.
Yaniv Lustig, Ph.D.
Neta Zuckerman, Ph.D.
Oran Erster, Ph.D.
Ministry of Health, Ramat Gan, Israel
Carmit Cohen, Ph.D.
Yitshak Kreiss, M.D.
Sheba Medical Center Tel Hashomer, Ramat Gan, Israel
Sharon Alroy-Preis, M.D.
Ministry of Health, Jerusalem, Israel
Gili Regev-Yochay, M.D.
Sheba Medical Center Tel Hashomer, Ramat Gan, Israel
Ella Mendelson, Ph.D.
Michal Mandelboim, Ph.D.
Ministry of Health, Ramat Gan, Israel
[email protected]
Disclosure forms provided by the authors are available with the full text of this letter at NEJM.org.
This letter was published on December 29, 2021, at NEJM.org.


"

 

[missy]

How Do We Treat Long COVID?

We dive into the new guidance for physicians

www.medpagetoday.com

How Do We Treat Long COVID?​

— We dive into the new guidance for physicians​

by Serena Marshall and Lara Salahi December 29, 2021




"

Millions of Americans are experiencing chronic, lingering, and debilitating symptoms months after recovering from COVID-19. The symptoms of so-called long COVID range from breathing problems to memory impairment, making it difficult for clinicians to pinpoint the syndrome and who may be at highest risk.



The NIH has directed $1 billion toward studying the syndrome, and some hospitals, including pediatric hospitals, have opened centers to research and care for patients experiencing long COVID.

On this week's episode, Jonathan Whiteson, MD, medical director of cardiac and pulmonary rehab at NYU Langone Medical Center in New York City, and spokesperson for the American Academy of Physical Medicine and Rehabilitation, joins us to explain how long COVID is being detected and treated, and the new guidance for physicians.

The following is an abridged transcript of his interview with "Track the Vax" host, Serena Marshall:

Marshall: So, I want to just dive right into if you have long COVID, what are some of the symptoms that you're seeing through your research?

Whiteson: So, long COVID means different things to different people who have had acute COVID. Typically we see people with persistent symptoms 4 to 6 weeks after their acute illness. And some of the most common symptoms include breathing difficulties, thinking difficulties, which we have termed "brain fog" -- that includes difficulties with focus and concentration and memory. Some people experience joint pains and aches, chest pains, and cough. So there's a multitude of different symptoms that some people have many and others have just a few.



Marshall: I mean, is there any that you saw that you were just really surprised by?

Whiteson: I think it's the, in some individuals, the multitude of symptoms. Some have reported up to 50 different symptoms as varied as bowel and bladder dysfunction, nasal congestion, and sinus pressures. Really, we have to understand that COVID can affect every single organ system, so from toes to nose and everything in between, we have seen people with a multitude of different symptoms, and they all vary, some to a greater or lesser extent, but they can persist. And so I think that's the greatest surprise. So many different organ systems, so many varied combinations of symptoms.

Marshall: And you do work with the American Academy of Physical Medicine and Rehabilitation, and they just released this series of statements and practice guidance for clinicians. Can you tell me a little bit about what those say?



Whiteson: So, as a physiatrist, I'm a rehabilitation physician, we call ourselves physiatrists.

Marshall: I haven't heard that. I like that term.

Whiteson: We are members of the American Academy of Physical Medicine and Rehabilitation, and we formed really the only multidisciplinary, multispecialty collaborative to form consensus guidance statements on the management of long COVID. And we've been working together now for just about a year, developing guidance statements for practitioners, physicians out there, that could be general practitioners, family practitioners, rehab doctors, other specialists who are taking care of individuals with long COVID, so that we could gather the evidence to date -- and that evidence is growing -- and put it into ordered statements and guidance for individuals managing those symptoms.

So, to date, we've published on fatigue, and the latest two statements we released were on breathing disorders and cognitive disorders. And in the not-too-distant future, we'll be publishing on autonomic issues. That's a part of the nervous system that controls heart rate and breathing patterns, as well as cardiovascular symptoms. And then also going on to talk specifically about neurologic issues and also pediatric cases of long COVID.



So, it's a very important process that we're going through, and physiatrists really are uniquely qualified to help guide the multidisciplinary effort needed to develop guidance. We see patients from a quality-of-life perspective, from a holistic perspective, from the perspective of a function. We are involved in research. We are used to leading teams in collaboration with other physicians, but also allied health professionals, including physical and occupational therapists and psychologists. And we helped solve the problem of what is going on with long COVID. How do we develop a treatment plan? How do we implement that for the patients?

Marshall: It really seems like you're creating a new specialty here.

Whiteson: So, interestingly, physiatry or the field of physical medicine rehabilitation has been around since post-Second World War, when Howard Rusk initiated this field. It's developed in many ways.

Marshall: I meant for treating long COVID.



Whiteson: Certainly in COVID. Well, long COVID is a new condition. It's a new problem that we're dealing with. We've known about it for 18 to 20 months now, but there's a need because individuals have a multitude of physical and functional limitations from the cognitive perspective, from cardiovascular and respiratory breathing perspectives.

So, again, as physiatrists, we're used to dealing with this multidisciplinary, multipronged approach to manage patients with this condition. But we have to meet the need. We know that there is, through estimates or using data from Johns Hopkins, the American Academy of Physical Medicine and Rehabilitation have put out a tracker tracking the number of cases, the number of individuals that may have long COVID, and we're getting close to 15 million individuals that have long COVID. This is a public health issue.

Marshall: I was so surprised by that number. I know we had heard estimates of 30 to 40% of those who test positive do become long haulers, but, like, seeing that number for almost 15 million, that was shocking.



Whiteson: It is shocking. It's tremendously impactful. There aren't enough physiatrists in the country to manage 15 million people who need assistance, which is why we're coming together with family practitioners, pulmonologists, cardiologists, neurologists, psychiatrists, to put together these guidance statements.

We need to spread the word. We need to get information out there to clinicians and physicians in the general arena, in family practice, to help manage these conditions. There are people, individuals who've had COVID who now have long COVID, who are desperate for care, and it's essential. And these individuals, many of them are young, they were working, they were active, they were participating in sports and other social activities. And now they're tremendously limited.

So, when we say this is a public health issue and a public health emergency, it's really true. It's impacting many, many individuals, taking them away from their productive lives. And as a collaborative, writing these consensus guidance statements really has helped get people on the right direction, back on track, and help return people to a quality of life and function.



Marshall: I mean, Dr. Whiteson, just to put that 15 million number in perspective, can you give us a comparison with heart disease or something?

Whiteson: Well, COVID has become the number one cause of death in the United States. We have now 800,000 people who have died from COVID. So, that is starting to eclipse other causes of death, of which the most common have been cardiovascular disease, chronic respiratory disorders, pulmonary disease, and cancer.

So, this is coming right up there in terms of that sort of public health emergency, taking people away from productive lives, and not allowing them to contribute to the economy in terms of working. And then also in terms of long-term disability and death. So, this is right up there at this time with cardiovascular disease, pulmonary disease, and malignancies as a leading cause of disability and death.

Marshall: It's just really something when you see it so starkly written there. So, when you talk about these guidances for different positions, someone who's not in the field, more general practitioners listening along with us today, what are some of those guidances that you can give them?



Whiteson: So, I'm going to stay general, but I will refer the practitioner who's listening and interested to look at the articles that have been published and they go into great detail. But the most important thing, of course, when we always evaluate a patient is to do a thorough history and physical examination. Of course, we want to understand what pre-existing conditions were because that does impact how sick people are when they have COVID. And the severity of COVID, probably, does give an indication to the severity of post-acute sequelae of COVID or long-haul COVID syndrome.

We found that with regards to lung disease, if people were hospitalized, if they had low oxygen levels on a pulse oximeter, if they were on a ventilator, the likelihood of them having persistent respiratory difficulties once they've recovered from the acute illness is going to be high.



So, a good history and physical is essential. And then, you know, doing some basic testing depending on what symptoms are most pressing, in the respect of the current guidance statements that we've put out in terms of, for instance, lung disease, breathing difficulties, checking somebody's oxygen saturation with a pulse oximeter, checking basic labs, including CBC, a basic metabolic, these are some of the basic tests that should be done.

If someone has persistent symptoms of breathing disorder or it's progressing, considering pulmonary function testing, a chest x-ray, progressing onto a CT scan if needed, the guidance statements really are there to help the general practitioner understand how to go through a stepwise evaluation of a patient with breathing difficulty, cognitive difficulty, fatigue, cardiovascular symptoms, but also understanding and recognizing when it's time to collaborate with a specialist. We know there aren't enough cardiologists or psychiatrists or psychologists or pulmonologists to see every patient. So, really, the weight of management does fall in the hands of the general practitioner, the family practitioner, and knowing when the thresholds are to call in a specialist to co-manage a patient.



Marshall: Given brain fog is a symptom, some people might wonder if some of this is psychosomatic, like PTSD from their experience with COVID.

Whiteson: So, that's a very interesting point. And, of course, there is no doubt that whether you have been infected by COVID or affected, because it's caused a change in our lifestyle, we have all been emotionally impacted by this COVID pandemic, whether it's ourselves, loved ones, our communities. So, there's no doubt that the human condition, we have a degree of anxiety and distress that's around the COVID pandemic. For those people who have had COVID, they've had at times a brush with severe illness, a loss of function perhaps, even death. If they've survived, they have feared for their lives. So, there's no doubt that there's a degree of anxiety. Some people have depression, PTSD, and this has to be addressed.



I think the caution is that we must make sure that clinicians who are evaluating patients with COVID don't immediately jump to the conclusion that the symptoms that individuals are presenting with are related to emotional disorders, and that has been a common occurrence. And part of the reason is many times when we are addressing individuals with symptoms, when we do some of the testing, we don't find abnormalities on standardized testing. It doesn't mean to say there isn't a disorder going on. It doesn't mean to say that these people, these individuals who have long COVID syndrome, don't have pathology. We just haven't been able to detect it as of yet.

We must be very cautious not to attribute it to mental health disorder; however, co-existent anxiety, stress, depression, PTSD, even sleep disorder needs to be evaluated for and managed. And it's only natural to think that along with the physical, along with the functional, along with the medical issues, there will be emotional issues too.



Marshall: It's interesting, you said a lot of the testing doesn't show up, the symptoms don't register in traditional testing yet. And so we've heard stories of people, you know, getting requests denied by their insurance company. So, how do you handle identifying this new disorder in an environment that's not set up with a safety-net system, that's not set up to really help such a high number of individuals go through an identification process?

Whiteson: This is a big problem. And you're absolutely right. And insurance companies, health systems, even going up to sort of the federal government in terms of, you know, how do we design a system that can take care of individuals? The American Academy of Physical Medicine and Rehabilitation has been working with governmental agencies. The Centers for Disease Control has been talking to governmental committees regarding the needs of individuals with disabilities and disability relating to COVID.



So, as an organization, and physiatrists in general, we advocate for our patients both on a local level, in our health systems, on an insurance-based level with insurance companies, we call their medical directors, we're appealing to them to recognize what's going on with our patients, but the work also needs to be done, the advocacy has to be done at a governmental level. This will take a government intervention, even acts of Congress, to change and to recognize long COVID as a disability and to provide the appropriate services.

And for individuals who are looking for short-term disability, long-term disability, because they have been impacted by COVID -- again, this is a new environment and, you know, as physiatrists, as the organization APM and all, we're working with insurance companies for them to know and realize exactly what's happening in the trenches with these patients. So, we advocate, we have to, it's a work in progress, and we haven't achieved everything yet, but we've made great inroads.



Marshall: One of the things we've heard is the best preventative measure of not having long COVID is not getting COVID and therefore getting a vaccine. Are you seeing that evidence correlation among your patients as well? Or are you seeing patients who've had vaccines have lower symptoms with long COVID?

Whiteson: Yeah, so individuals who've not been vaccinated are more likely to have severe disease and are more likely to have long COVID, more symptoms, and a greater impact on their function, quality of life, and overall health. We have seen breakthrough cases, individuals who've been vaccinated who have got COVID and have long COVID, but those symptoms tend to be milder and resolve in a quicker way.

We're still gathering information. We're still learning. We do not have all the answers yet. The trends appear to be, if you are vaccinated and you get breakthrough COVID, the likelihood of long-haul symptoms are less, the severity is less, and the duration is less.



Marshall: Why isn't long COVID, do you think, talked about more? I feel like we hear so much about obviously the macabre, the 800,000 that have died, very important to prevent those deaths. But in order to change the conversation and get those who are still resistant to vaccines on board, you know, this is perhaps more of a realistic sickness to grasp onto.

Whiteson: Yeah. So, I think that's another important point. We do listen to statements from the government and medical representatives saying, you know, get vaccinated and you're much less likely to have severe disease, you're much less likely to die. I think those are very important facts. But the majority of people who have COVID are going to survive, and many of them, as we've already seen, 30 to 40% as you mentioned, 15 million people on estimate so far are going to have long COVID symptoms.



And that's very distressing. When you have long COVID symptoms, when you have brain fog, when you cannot think, when you cannot focus, when you cannot calculate, when you get lost, when you step off a train and you don't know which way to turn, when you cannot breathe, when you're having chest pain, when you get dizzy when you stand up, these are very impactful symptoms.

Listen, none of us want to die. We all want to be alive. But living with long COVID is very challenging. I think for, you know, our listeners, in terms of practitioners and anyone who listens who's an individual who's had COVID, overall our perspective is that individuals with long COVID do improve. Some improved quickly, weeks to months, many we're seeing people who were infected probably January, February of 2020, so we're now coming up to nearly 2 years and they're still symptomatic. There are fluctuations and variations in their symptoms, days and weeks where they feel better, days and weeks where they feel worse, exacerbations if they over-exert themselves, both physically and mentally, but the general trend has been a positive one.



Whilst there are still some who have persistent symptoms, many do improve and many do recover. However, your point is well taken. We need to spread the word. We need to use this as a tool to encourage people to be vaccinated, to minimize their risk of infection, severe infection, and long COVID.

Marshall: You said many do recover. Do you see this, in 5, 10 years, being an illness that has to be managed like diabetes or something that you will recover from and move on from more acute?

Whiteson: So, I wish I had the crystal ball to answer that question. We have a sense when we look back at other viral illnesses, other epidemics, not on the scale of this, but there have been other viral infections that have caused significant side effects and multi-system involvement. When we look at that, we do see there's a percentage that will have long-term symptoms, I personally recall several that I take care of who have had long-term symptoms, and this is five, one patient even 10 years later, following a severe respiratory infection, so there can be long-term consequences.



And let's not forget there are some individuals who have COVID who are so sick, I have a number of patients who've had lung transplants. These people never live their previous lifestyle again. Their life is forever changed. So, yes, while many people with long COVID will recover and will recover completely, and we certainly hope in time they'll put it behind them and they'll forget altogether they had this, in a good way. There are going to be many that live with long-term consequences, long-term disability, because COVID impacted their organ systems so severely.

Marshall: What about kids?

Whiteson: So, let me just say that I take care of adults and not children. However, the American Academy of Physical Medicine and Rehabilitation has a strong pediatric representation. There will be a pediatric consensus statement released in the not-too-distant future. So, I'm not so qualified to talk about kids, but we do know kids get COVID. We do know kids get long COVID. The same principles of vaccination are really important, boosting the children as well. And having those children see physiatrists who specialize in pediatric disabilities is very, very important.



And, again, the collaborative really does emphasize that coordination of care with physiatrists, with pediatricians, to make sure that everyone understands how to evaluate the children, how to manage them, how to monitor them going forward, and to steer them in the right direction.

Marshall: It really is such a fascinating conversation. Dr. Whiteson, thank you so much for joining us.

Whiteson: Thank you, indeed.

"

 

[missy]

In Quebec, a dreadful sense of déjà vu​

Quebec is in disbelief. In just two weeks, the omicron variant turned the French-speaking Canadian province into the country’s Covid hot spot, a status it held before and thought it was done with. While all of Canada is struggling to contain the newest wave of infections, leading to the cancelation of the remainder of the world junior hockey championship, record cases in Quebec have set it apart from other provinces. No one is quite sure why, but a slow start to the vaccine booster campaign and increased social contacts before Christmas—in a place known for its joie de vivre—have something to do with it. To avoid a holiday disaster, the Quebec government resorted to a string of restrictions that the population thought were history. When authorities ordered gyms, schools, theaters and bars to close within hours on Dec. 20, many shared the feeling of Vincenzo Guzzo, chief executive officer of movie theater chain Cinemas Guzzo. “It’s Groundhog Day all over again,” Guzzo told BNN Bloomberg Television, referring to the film where a weatherman played by Bill Murray relives the same day over and over. Residents wait in line outside a Covid-19 testing center in Montreal Photographer: Christinne Muschi/Bloomberg Quebec implemented some of the toughest measures in North America during the pandemic, including a curfew that ran from January through May. Traumatized by outbreaks at long-term care facilities that killed hundreds of elderly people and required help from the military, the population by and large complied. But the hyper-contagious variant made for an unprecedented situation. On Dec. 13, Quebec reported 1,628 new infections. About two weeks later, the province had more than 13,000 new cases, a staggering increase. And that’s most likely an underestimate because people increasingly turn to rapid tests at home, which don’t get reported to the government. Or they’ve given up on getting more-accurate PCR tests because it’s hard to secure a spot. The full impact on hospitalizations has yet to be seen, but authorities are trying to slow it as much as possible. The virus is so rampant that many restaurants, which can still operate at reduced capacity, have decided to take a prolonged holiday break. It retrospectively seems surreal that authorities, as recently as Dec. 7, doubled the authorized limit for Christmas gatherings. The surprise move was to “reward” Quebeckers for “great work on vaccination, on respecting the rules,” Health Minister Christian Dube said. But on Christmas Eve, Premier Francois Legault struck a different tone after three rounds of restrictions within days. “The next weeks are going to be difficult,” he wrote. “It's going to be very important to continue our efforts and stick together, even if we are fed up.”—Sandrine Rastello