Coronavirus updates November 2022

[missy]

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COVID-19 Affects Brain 6 Months After Symptoms, Research Finds​

Jay Croft
November 22, 2022

Scientists have found that COVID-19 causes brain "abnormalities" even six months after symptoms are gone, according to an upcoming report to the Radiological Society of North America.
They found changes to the brain stem and front lobe in areas of the brain associated with fatigue, insomnia, anxiety, depression, headaches, and cognitive issues.
About 20% of adults will have long-term effects from COVID-19, according to the CDC. Neurological symptoms associated with long COVID include poor concentration, headaches, and sleep problems. Long COVID can also cause changes to the heart, lungs, and other organs, the RSNA says.

In this study, researchers used a special MRI to detect and monitor neurological conditions such as microbleeds, vascular malformations, brain tumors, and stroke.
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"Group-level studies have not previously focused on COVID-19 changes in magnetic susceptibility of the brain despite several case reports signaling such abnormalities," said study co-author Sapna S. Mishra, a Ph.D. candidate at the Indian Institute of Technology in Delhi, in SciTechDaily. "Our study highlights this new aspect of the neurological effects of COVID-19 and reports significant abnormalities in COVID survivors."
Scientists compared imaging of 46 patients who had recovered from COVID and 30 who had been healthy. The images were taken within six months of recovery.
"Changes in susceptibility values of brain regions may be indicative of local compositional changes," Mishra said. "Susceptibilities may reflect the presence of abnormal quantities of paramagnetic compounds, whereas lower susceptibility could be caused by abnormalities like calcification or lack of paramagnetic molecules containing iron."

The researchers will conduct similar studies on the same group of participants to see if the COVID-19 affects continue over time.

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[missy]

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6 tips to avoid getting your family sick during holiday travel​

Infectious-disease experts share tips on avoiding covid, RSV and the flu​

Advice by Hannah Sampson
Staff writer
November 23, 2022 at 11:12 a.m. EST

With Thanksgiving and winter holidays around the corner, travelers are gearing up for busy airports and hectic trips to see family and friends. But the coronavirus threat that kept many home the last two holiday seasons isn’t gone, and it’s joined by more respiratory illnesses like the flu and respiratory syncytial virus that are sending people to the hospital this year.

“Covid is still floating around, RSV’s floating around, influenza’s increasing,” said Abinash Virk, an infectious disease specialist at the Mayo Clinic in Minnesota. “All three of them, particularly in frail people or immune-compromised people, are really nasty.”
What’s the difference between RSV, the flu and covid-19?
Michelle Barron, senior medical director of infection prevention at UC Health in Colorado, said this time of year often brings norovirus outbreaks as well.
“People have been talking about the ‘tripledemic’” — referring to covid, flu and RSV, a common virus that usually causes mild, cold-like symptoms — “I’m like no, this is just the season of grossness,” she said.






Unlike last holiday season, masks are no longer required on planes or other forms of transportation. But travelers may still want to take extra precautions to avoid bringing germs along on their trip — especially if they’re planning to see grandparents, new babies or other at-risk friends and family. Health experts say people should take precautions to protect the most vulnerable people they plan to spend time with.
RSV, covid and flu push hospitals to the brink — and it may get worse
“At the end of the day, people want to enjoy themselves, people want to gather and they want to travel and they should,” Barron said. “But you don’t want to be sick on your vacation.”

Stay up to date on vaccines​

New omicron-specific boosters are available for people age 5 and older, and kids as young as 6 months can get their primary course of the vaccine. The Centers for Disease Control and Prevention recommends people 5 and older get an updated booster if it’s been at least two months since their last vaccine dose.


Flu shots are available for people age 6 months and older.
“If people have not had a flu vaccine, now is the time to get one,” said Kris Bryant, a pediatric infectious-disease specialist at Norton Children’s Hospital in Louisville and a member of the American Academy of Pediatrics Committee on Infectious Diseases.
There is no vaccine available yet to prevent RSV, which can be particularly severe in young children, older adults and immunocompromised people.
Thanksgiving travel will be crowded, but not as chaotic as the summer

Be cautious leading up to a trip​

Virk said she’s told her own family members to start being cautious a week before they visit grandparents. That means avoiding potentially risky behavior like eating at restaurants indoors, going unmasked in crowded indoor spaces or gathering with large groups of people inside.
Barron said a week is “probably really, really cautious.”






“Most things you worry about, especially right now, about three days is when it’s going to hit you,” she said.
Holiday travelers face trio of illnesses, as RSV, flu spike in the DMV

Mask while traveling​

You don’t legally have to wear a mask most places anymore. But, experts say, it’s still a good idea — especially if you’re trying to avoid getting sick and spreading illness to others.
Bryant acknowledged that masking is a choice now more than a mandate; it’s a choice she made when visiting her newborn grandchild after she’d been working and attending a meeting.
“If people are going into crowded environments where they don’t always have the choice to step away from somebody who’s coughing, they can absolutely choose to wear a mask to protect themselves and to protect the others in their family who may be vulnerable,” she said.
Virk said she would “definitely” wear a mask if she were not able to separate herself from crowds.






The kinds of high-quality masks that are recommended to protect against the coronavirus, like an N95 or KN95, “will also protect against influenza and RSV as well,” said Jessica Tuan, an infectious diseases doctor at Yale Medicine.
“If you’re wearing a mask, don’t feel uncomfortable being the only one doing it,” she said.
You don’t have to wear a mask on planes. Do it anyway, experts say.

Wash and wash and wash your hands​

You probably perfected your hand-washing routine in the early days of the pandemic — and then, perhaps, let it slide after the CDC said the coronavirus primarily spreads in small particles or droplets from person to person.
But good hand-hygiene remains important, especially as multiple viruses circulate, experts said. As a reminder, the washing should last “at least 20 seconds,” Tuan said.
“Hand-washing is very important and I know we’ve heard a lot about that during the pandemic,” said Bryant, who also said people should be careful to clean their hands before holding a baby. “But RSV is in nasal secretions. If those nasal secretions get on a surface, they can live there. They can be spread that way.”






The CDC says that RSV can survive “for many hours” on hard surfaces and for shorter amounts of time on soft surfaces, including hands.
Even beyond the high-profile triple threat of the season, Barron said washing your hands should be a priority to protect against “dirt and other things that are easily communicable.”
“It is a huge way to transmit all sorts of things and it’s really gross if you really thought about all the stuff that touches seats and handles and doorknobs,” she said.
4 health experts on the covid travel precautions we should keep

Test (more than once) before gathering​

Virk recommends testing for coronavirus three days before traveling and on the day of travel as a precaution. The Food and Drug Administration advises repeat, or serial, testing with home antigen tests “to reduce the risk an infection may be missed” with a false negative result.










Barron warns that while repeat testing may improve the sensitivity of home tests, they still aren’t foolproof.
“No test is 100 percent,” she said.
As a rule, if someone has any symptoms, they should test, Virk said.
The CDC says people should stay home for at least five days and isolate if they test positive for coronavirus. Without symptoms or with improving symptoms, isolation can end after Day 5. People who have moderate or worse illness should isolate through Day 10.
People who test positive should wear a mask through Day 10, the agency says. And until Day 11, they should avoid being around people who are more susceptible to serious illness from the virus.
While there is no rapid home test for flu or RSV, experts say it’s good to know what you’re dealing with if you are sick.
“Particularly if someone is immune-compromised and they know it’s influenza or they know it’s covid, there are treatments,” Virk said.
Will the airport be chaotic this holiday? Your questions, answered.

Know when to bow out​

Bryant said it might have been common before the pandemic for someone who had mild cold symptoms to show up to a gathering and get everyone sick.


“We’ve learned not to do that,” she said. “People who get sick, even with mild cold symptoms, should stay home and stay away from babies.”
Tuan said travelers might want to reconsider visiting family who are moderately to severely immunocompromised, or very young kids who might not have robust immune systems yet.
“If you are immune-compromised, travel on a need-to-go basis,” she said.
Barron agreed that someone who is feeling unwell should avoid gatherings. If that isn’t an option, they should wear a mask, stay apart from other people or stick to outdoor activities.
“Be responsible that if you do get sick, have that Plan B,” she said.

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[missy]

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Fauci Pleads With Americans to Get COVID Shot in Final White House Briefing​

By Steve Holland and Trevor Hunnicutt
November 23, 2022

WASHINGTON (Reuters) - Dr. Anthony Fauci, the U.S. health official celebrated and vilified as the face of the country's COVID-19 pandemic response, used his final White House briefing on Tuesday to denounce division and promote vaccines.
Fauci, who plans to retire soon as President Joe Biden's top medical adviser and top U.S. infectious disease official, has dealt with the thorny questions around health crises from HIV/AIDS to avian flu and Ebola.
But it was his handling of COVID - and his blunt assessments from the White House podium that Americans needed to change their behavior in light of the pandemic - that made him a hero to public health advocates while serving under former President Donald Trump, a villain to some on the right and an unusual celebrity among bureaucratic officials used to toiling in obscurity. Fauci has regularly been subjected to death threats for his efforts.
True to form, Fauci used his final press briefing to strongly encourage Americans to get COVID vaccines and booster shots, and touted the effectiveness of masks, all of which became partisan totems in the United States.

The United States leads the world in recorded COVID-19 deaths with more than one million.




After 13 billion doses of COVID-19 vaccines given worldwide, Fauci said, there is "clearly an extensive body of information" that indicates that they are safe.
"When I see people in this country because of the divisiveness in our country ... not getting vaccinated for reasons that have nothing to do with public health, but have to do because of divisiveness and ideological differences, as a physician, it pains me," Fauci said.
"I don't want to see anybody hospitalized, and I don't want to see anybody die from COVID. Whether you're a far-right Republican or a far-left Democrat, doesn't make any difference to me."

WHO TO TRUST
White House COVID response coordinator Dr. Ashish Jha, who joined Fauci at the podium, said the administration is trying to promote physicians as sources of information about the pandemic rather than uninformed voices.
"You can decide to trust America's physicians, or you can trust some random dude on Twitter," said Jha.
"For journalists and for people who run platforms, what I would say is, you should be thinking about what your personal responsibility is. And do you want to be a source of misinformation and disinformation? That's up to up to those individuals," Jha said.

Fauci is stepping down in December after 54 years of public service. The 81-year-old has headed the U.S. National Institute of Allergy and Infectious Diseases, part of the National Institutes of Health, since 1984.

The veteran immunologist has served as an adviser to seven U.S. presidents beginning with Republican Ronald Reagan. He made his first appearance at the White House press briefing in 2001, according to the broadcaster C-SPAN.

In the first months of the pandemic in 2020, Fauci helped lead scientific efforts to develop and test COVID-19 vaccines in record time.

He became a popular and trusted figure among many Americans as the United States faced lockdowns and rising numbers of COVID-19 deaths, even inspiring the sale of cookies and bobblehead dolls featuring his likeness.

However, Fauci drew the ire of Trump and many Republicans for cautioning against reopening the U.S. economy too quickly and risking increased infections, and for opposing the use of unproven or ineffective treatments such as the malaria drug hydroxychloroquine promoted by some on the right.

Democrats accused Trump of presiding over a disjointed response to the pandemic and of disregarding advice from public health experts including Fauci. Trump in October 2020, weeks before his re-election loss, called Fauci "a disaster" and complained that Americans were tired of hearing about the pandemic.

Republican lawmakers including fierce critic Senator Rand Paul, with whom Fauci tangled during Senate hearings, have vowed to investigate him.

On Tuesday, Fauci said he "will absolutely cooperate fully" in any congressional oversight hearings launched by Republicans next year, when they take control of the House of Representatives following November's elections.

(Writing by Trevor HunnicuttEditing by Bill Berkrot)
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[missy]

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Without Guidelines, Docs Make Their Own Long COVID Protocols​

Lisa Rapaport
November 22, 2022






Diagnosing long COVID is something of an art for doctors who, without any formal criteria, say they know it when they see it. Treating the condition requires equal combinations of skill, experience, and intuition, and doctors waiting for guidelines have started cobbling together treatment plans designed to ease the worst symptoms.
Their work is urgent. In the U.S. alone, as many as 29 million people have long COVID, according to estimates from the American Academy of Physical Medicine and Rehabilitation.
"Patients with long COVID have on average at least 14 different symptoms involving nine or more different organ systems, so a holistic approach to treatment is essential," says Janna Friedly, MD, executive director of the Post-COVID Rehabilitation and Recovery Clinic at the University of Washington in Seattle.

For acute COVID cases, the National Institutes of Health has treatment guidelines that are taking a lot of the guesswork out of managing patients' complex mix of symptoms. This has made it easier for primary care providers to manage people with milder cases and for specialists to come up with effective treatment plans for those with severe illness. But no such guidelines exist for long COVID, and this is making it harder for many doctors – particularly in primary care – to determine the best treatment.
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While there isn't a single treatment that is effective for all long COVID symptoms – and nothing is approved by the FDA specifically for this syndrome – doctors do have tools, Friedly says.
"We always start with the basics – making sure we help patients get enough restorative sleep, optimizing their nutrition, ensuring proper hydration, reducing stress, breathing exercises, and restorative exercise – because all of these are critically important to helping people's immune system stay as healthy as possible," she says. "In addition, we help people manage the anxiety and depression that may be exacerbating their symptoms."
Fatigue is an obvious target. Widely available screening tools, including assessments that have been used in cancer patients and people with chronic fatigue syndrome, can pinpoint how bad symptoms are in long COVID patients.
"Fatigue is generally the number one symptom," says Monica Verduzco-Gutierrez, MD, chair of rehabilitation medicine and director of the COVID-19 Recovery Clinic at the University of Texas Health Science Center in San Antonio. "If a patient has this, then their therapy program has to look very different, because they actually do better with pacing themselves."
This was the first symptom tackled in a series of long COVID treatment guidelines issued by the medical society representing many of the providers on the front lines with these patients every day – the American Academy of Physical Medicine and Rehabilitation. These fatigue guidelines stress the importance of rest, energy conservation, and proper hydration.

For patients with only mild fatigue who can still keep up with essential activities like work and school, activity programs may begin with a gradual return to daily routines such as housework or going out with friends. As long as they have no setbacks, patients can also start with light aerobic exercise and make it more intense and frequent over time. As long as they have no setbacks in symptoms, they can ramp up exercise by about 10% every 10 days.
But with severe fatigue, this is too much, too soon. Activity plans are more apt to start with only light stretching and progress to light muscle strengthening before any aerobic exercise enters the picture.

"Traditional exercise programs may be harmful to some patients with long COVID," says Verduzco-Gutierrez. "Many cannot tolerate graded exercise [where exertion slowly ramps up], and it actually can make them worse."
There's less consensus on other options for treating fatigue, like prescription medications, dietary supplements, and acupuncture. Some doctors have tried prescription drugs like the antiviral and movement disorder medication amantadine, the narcolepsy drug modafinil, and the stimulant methylphenidate, which have been studied for managing fatigue in patients with other conditions like cancer, multiple sclerosis, traumatic brain injuries, and Parkinson's disease. But there isn't yet clear evidence from clinical trials about how well these options work for long COVID.
Similarly, interventions to tackle neurological symptoms and cognitive problems borrow a page from treatments used for other conditions like strokeand dementia – but require changes to meet the needs of those with long COVID. Four in five long COVID patients with neurological and cognitive issues have brain fog, while more than two-thirds have headaches, and more than half have numbness and tingling in their extremities, loss of taste, loss of smell, and muscle pain, one study suggests.
Patients with deficits in areas like memory, attention, executive function, and visual and spatial planning may get speech therapy or occupational therapy, for example – both approaches that are common in people with cognitive decline caused by other medical conditions.
Doctors also promote good sleep practices and treating any mood disorders – both of which can contribute to cognitive problems. But they often have to skip one of the best interventions for improving brain function – exercise – because so many long COVID patients struggle with fatigue and exertion or have cardiovascular issues that limit their exercise.
The lack of formal guidelines is especially a problem because there aren't nearly enough specialists to manage the surge of patients who need treatment for issues like fatigue and brain fog. And without guidelines, primary care providers lack a reliable road map to guide referrals that many patients may need.
"Given the complexity of long COVID and the wide range of symptoms and medical issues associated with long COVID, most physicians, regardless of specialty, will need to evaluate and treat long COVID symptoms," says Friedly. "And yet, most do not have the knowledge or experience to effectively manage long COVID symptoms, so having guidelines that can be updated as more research is conducted is critical."

One barrier to developing guidelines for long COVID is the lack of research into the biological causes of fatigue and autonomic dysfunction – nervous system damage that can impact critical things like blood pressure, digestion, and body temperature – that affect so many long COVID patients, says Alba Miranda Azola, MD, an assistant professor and co-director of the Post-Acute COVID-19 Team at Johns Hopkins University School of Medicine in Baltimore.

Research is also progressing much more slowly for long COVID than it did for those hospitalized with severe acute infections. The logistics of running rigorous studies to prove which treatments work best for specific symptoms – information needed to create definitive treatment guidelines – are much more complicated for people with long COVID who live at home and may be too exhausted or too preoccupied with their daily lives to take part in research.

The vast number of symptoms, surfacing in different ways for each patient, also make it hard to isolate specific ways to manage specific long COVID symptoms. Even when two patients have fatigue and brain fog, they may still need different treatments based on the complex mix of other symptoms they have.

"All long COVID patients are not equal, and it is critical that research focuses on establishing specific descriptions of the disease," Azola says.


The National Institutes of Health is working on this through its long COVID Recover Initiative. It's unclear how long it will take for this research to yield enough definitive information to inform long COVID treatment guidelines similar to what the agency produced for acute coronavirus infections, and it didn't respond to questions about the timeline.

But over the next few months, the National Institutes of Health expects to begin several clinical trials focused on some of the symptoms that doctors are seeing most often in their clinics, like fatigue, brain fog, exercise intolerance, sleep disturbances, and changes in the nervous system's ability to regulate key functions like heart rate and body temperature.

One trial starting in January will examine whether the COVID-19 drug Paxlovid can help. A recent Department of Veterans Affairs study showed patients treated with Paxlovid were less likely to get long COVID in the first place.


Some professionals aren't waiting for the agency. The Long Covid Research Consortium links researchers from Harvard and Stanford universities; the University of California, San Francisco; the J. Craig Venter Institute; Johns Hopkins University; the University of Pennsylvania; Mount Sinai; Cardiff; and Yale who are studying, for instance, whether tiny blood clots contribute to long COVID and whether drugs can reduce or eliminate them.

"Given the widespread and diverse impact the virus has on the human body, it is unlikely that there will be one cure, one treatment," says Gary H. Gibbons, MD, director of the National Heart, Lung, and Blood Institute at the National Institutes of Health. "This is why there will be multiple clinical trials over the coming months that study a range of symptoms, underlying causes, risk factors, outcomes, and potential strategies for treatment and prevention, in people of all races, ethnicities, genders, and ages."


SOURCES:


American Academy of Physical Medicine and Rehabilitation: "PASC Dashboard."


Janna Friedly, MD, executive director, Post-COVID Rehabilitation and Recovery Clinic, University of Washington.


National Institutes of Health: "Coronavirus Disease 2019 (COVID-19) Treatment Guidelines," "RECOVER: Researching COVID," "RECOVER Program Takes First Steps in Advancing Toward Clinical Trials to Better Understand Long COVID."
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[missy]

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Will the vaccine protect me from long Covid?​

I’m over 70 and I’m vaccinated, boosted and received my bivalent booster a couple of weeks ago. I’m one of the lucky ones who hasn’t contracted Covid-19 or any of its variants. My question is: If a person contracts Covid now, do vaccination and boosters help prevent long Covid – or is that just the roll of the dice? Cindy, Washington The answer is yes — to both scenarios. “Yes, vaccinations and boosters help prevent long Covid, and yes it’s also a roll of the dice,” says Jessica Justman, an infectious diseases specialist and epidemiologist at Columbia University. SARS-CoV-2 has been steeped in uncertainty from the start, and there is still so much we don’t know about the virus and its effects on humans. That applies here, too. The diverse array of lingering symptoms that have come to be commonly known as long Covid might, in fact, be one of the biggest mysteries associated with the disease. But we can safely presume that you won’t get long Covid if you’ve never been infected with Covid. Stopping any disease totally is tough, but there are preventative measures that lower your risk of infection, Justman says. Those include “vaccination, masking, social distancing, hand hygiene and using rapid tests before large family gatherings.” These practices are especially important during the holiday season, which coincides with the season of winter illnesses. They can also reduce the chance you’ll become severely ill if you’re infected, which also makes long Covid less likely, Justman says. A few published studies have suggested long Covid occurs less frequently among those who had Covid after being vaccinated. At least one study has shown rates of long Covid decreasing with every additional round of shots. But there is a lot of work left to understand the illness. And vaccines don’t offer perfect protection. “This is where the roll of the dice comes into play,” Justman says. If you have certain conditions that put you at increased risk of long Covid, such as allergies and certain lung diseases, limiting exposure the disease is also important, she says. So now that the holiday season is in full gear, make sure to stock up on hand sanitizer, masks and rapid tests alongside the bubbly and blinis. — Kristen V. Brown "

 

[missy]

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COVID-19 in China and global concern​

KATELYN JETELINA NOV 29

After Omicron emerged as a highly contagious variant of concern, the majority of the world accepted a harm reduction strategy: get vaccines in as many arms as possible, then slowly open up. In many countries, this turned out to be a good public health strategy to reduce death, minimize stress on healthcare systems, improve quality of life, improve the economy, etc. However, China continues to attempt a zero-COVID strategy—very, very tight restrictions—in an attempt to stop all transmission.

While China’s strategy has an upside, like reduced deaths, reduced long COVID rates and decreased chances of mutations, it has massive downsides. It’s clear that the ever-stricter measures fail to keep up with more-transmissible variants while becoming increasingly costly to society. This has caused country-wide protests sparked by frustration, anger, discontent, and despair.

COVID-19 seems to be on the verge of exploding in China. They are reporting record-high numbers—nearly 40,000 new infections per day. The biggest concern is China’s incomplete immunity wall when faced with infections:

1. China does have a highly vaccinated population—about 90% are vaccinated with the primary series. This is higher than the United States. However, quality (not just quantity) of the vaccine is important. China rolled out Sinopharm and SinoVac—inactivated vaccines that are just not very effective against Omicron.
2. Their booster rate, and specifically who is boosted, is abysmal. Only 30% of 80+ year olds have one booster, for example. We have plenty of evidence showing the importance of boosters among the most vulnerable.
3. Infection-induced immunity is low. While preventing infections is the safest route, we have more than 30 studies showing hybrid immunity (vaccine + infection) builds a more complex immunity wall for the virus.

Impact​

Last winter, we witnessed what Omicron could do in a population with an incomplete immunity wall—death rates in Hong Kong went vertical. It was simply disastrous.

​

What could happen across all of China? A scientific publication in Nature Medicine predicted a grim picture earlier this year. They ran a number of models with varied infection rates, booster rates, vaccine efficacy, the use of non-pharmaceutical interventions (like masks), and more. In conclusion, over a 6 month period, China would experience:

• 112.2 million symptomatic cases
• 2.7 million ICU admissions, exceeding their ICU capacity by 15.6 times
• 1.55 million deaths, 75% of them among those aged 60 years and older

Solution?​

From a public health perspective, I’m not sure how this ends well for China, as there are very few ways out of this scenario.

The best option is to vaccinate as many people as possible, especially older adults, through a very intense, massive public health campaign. They are starting to do this, but too late. And, ideally, they would use mRNA vaccines. China has ~10 mRNA vaccines in the development pipeline, but to my knowledge, none are close to roll-out. My hope is that they will pivot to American vaccines, soon, but I’m not holding my breath. They could wait for second generation vaccines that stop transmission, but this will take a lot of time.

A vaccine campaign has challenges, too—mainly lack of trust. A great articlecovered why China has not implemented a vaccine mandate even though they implement other very strict measures: dramatic social resistance.

Japan has released scientific results of the first effective anti-viral for non-high risk people. I would pair this with Paxlovid, better ventilation, and masks and hope for the best.

In all, I think the situation in China is about more than public health. It’s about politics, control, autonomy from the West, and so much more, which makes solving the public health problem that much more difficult.

Global implications​

We should be very concerned for the people of China. But this situation also has global implications.

If the flood gates open, there will be an impact on the economy. We’ve seen throughout the pandemic that healthy people equals a healthy economy. A massive outbreak in China would have a global cascading impact on supply chains.

It could also impact viral evolution. If COVID-19 takes hold in China, there will be little to stop the virus from jumping person-to-person in a network of 1.4 billion people—about 20% of the global population. Some mutations arise from persistent infection with immunocompromised people (we think this is how Omicron developed), but the more a virus jumps, the more opportunity it has to randomly mutate. This is how we got Delta, for example.

To add fuel to the fire, global COVID-19 surveillance is down 90%. So if we do get a mutated virus, we won’t have a lot of warning. In fact, we don’t even know which Omicron subvariant is causing the current wave in China.

With more than 500 subvariants circulating, we are seeing more second-generation subvariants than ever. They are popping up independently across the globe. This suggests that we may finally be seeing ladder-like evolution patterns, which would be good news, as we can finally start predicting where this virus may go, like the flu or other coronaviruses. Given the situation in China, I really hope we won’t see Pi—the next variant of concern— but there’s a possibility.

Bottom line​

China backed themselves into a grim corner. And all we can do is watch how this unfolds in the next few weeks. And, as we’ve seen throughout the pandemic, what happens in one country can directly impact everyone else.

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[missy]

From Consumer Lab

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What's the evidence for the updated boosters?
The FDA's authorizations (and CDC's recommendations) of the updated Pfizer and Moderna boosters were based on the safety evidence for the original Pfizer and Moderna vaccines, clinical data from Pfizer and Moderna showing efficacy of the companies' Omicron BA.1-targeting bivalent booster candidates, and preclinical studies in mice showing efficacy of the Omicron BA.4/BA.5-targeting boosters (Pfizer Press Release, 8-22-22; Moderna Press Release, 8-23-22).

Since introduction of the updated (bivalent) boosters, analysis of data from the U.S. suggests that it reduces the risk of symptomatic COVID-19 infection, particularly if a booster had not been received for several months: Among adults who had received the primary series and up to 2 shots of the original COVID-19 mRNA boosters, those who received an updated booster at least 8 months after their last COVID-19 shot were about half as likely to develop symptomatic COVID-19 as those who didn't receive the updated booster. The benefit was slightly lower among older people, and the benefit was also lower among those who had received their most recent COVID-19 shot only 2 to 3 months earlier — for whom the updated booster reduced the risk of symptomatic COVID-19 by 28% to 31% (Link-Gelles, MMWR Morb Mortal Wkly Rep 2022).

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[missy]

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Should We Bring Masks Back Into the Classroom?​

— Mask mandates can ease the burden on our healthcare system​

by Zachary Rubin, MD, and Melanie Matheu, PhD November 27, 2022

Influenza and respiratory syncytial virus (RSV) infections have skyrocketed this year relative to previous years, with infections from both viruses occurring earlier and increasing faster than any cold and flu season in recent history. Over the past couple of months, many pediatric hospitals have reported running out of beds necessary to treat severe influenza, RSV, and SARS-CoV-2 infection. The surge in respiratory virus infection has also caused problems for working families. More than 100,000 Americans missed work in October to take care of their sick kids. This is an all-time high, according to data from the U.S. Bureau of Labor Statistics. Families are struggling to keep their kids in school while many schools have closed due to the increase in illnesses.



In the school setting, masks can help slow the spread of viral respiratory infections. Masks work both as source control, limiting the amount of virus in the air from those infected, and as exposure control, limiting the amount of virus inhaled by someone healthy. During the 2020-2021 school year, when schools mandated masks and encouraged physical distancing, influenza and RSV infections were virtually non-existent. Reintroducing masks in places of high exposure, such as schools, is a simple and effective method of reducing infection from various pathogens in both children and adults. The recent report, "Lifting Universal Masking in Schools – COVID-19 Incidence Among Students and Staff," offers real-world evidence on the correlation between masking and reduced incidence of COVID-19 in schools. While variable conditions -- from the type of mask to a school's ventilation system -- can change the calculus for different schools, the benefits of masking are clear. Indeed, our understanding of the benefits of masking is nothing new: masks have been a required part of personal protection equipment (PPE) in many hospital settings for decades due to their ability to protect healthcare workers from infectious viruses.



While some have expressed concern that masking in schools may impede learning, psychologists have found that masks do not impede language development in the classroom setting or development of facial recognition skills. Additionally, a January 2022 study found that over a 1-year study period, schools that required masks were 14% less likely to experience school closure. With the understanding that a critical part of childhood development is the learning and socialization that takes place in school, keeping kids healthy and schools open needs to be a priority.

In examining the possible reintroduction of masks in schools to slow the surge in respiratory infections, we also need to consider what's driving these cases. Many media articles have attempted to link the recent viral respiratory surge to "immunity debt." This term was coined in a 2021 paper and was not discussed in the medical literature previously. It asserts that "The reduction of infectious contacts secondary to hygiene measures imposed by the pandemic may have led to a decreased immune training in children and possibly to a greater susceptibility to infections in children." This hypothesis has led many to believe that COVID-19 mitigation strategies, such as mask-wearing and physical distancing, has somehow weakened children's immune systems. However, there is limited scientific evidence that such a phenomenon exists and debate is ongoing among healthcare professionals. In fact, in Sweden, where widespread mask mandates were not implemented, there was an unusual surge of RSV cases in the fall of 2021, prompting health officials to recommend keeping older children at home if they had infant siblings. The same logic applies in the U.S., where masking was less prevalent in some parts of the country than others, yet the current spikes in pediatric infections aren't unique to the regions with stricter masking mandates.



So, what might be causing this surge? Patterns of respiratory disease have significantly shifted during the COVID-19 pandemic. This shift is historic. According to the CDC, the peak of the influenza season is most often between December and March. Prior to 2020, RSV onset was predictable, most often starting in mid-October and lasting until May. However, RSV circulation started to rise in the spring of 2021 and peaked in July. Recently, RSV started to rise in September, making the 2022-23 RSV surge unusual. In the U.S., our hospital systems are ill-equipped to care for the huge number of respiratory virus infections from this unusual co-circulating trifecta of COVID-19, influenza, and RSV.

Addressing the surge in respiratory viral infections as quickly as possible is in the best interest of children. The already impacted healthcare system will struggle and perhaps simply run out of staffed beds for critical care if the high rate of severe infections continues to increase in the winter months. There is, however, one well studied, simple solution: Bring back masks in the classroom.

Zachary Rubin, MD, is a pediatrician specializing in allergy and immunology. Melanie Matheu, PhD, is a scientist and the founder of Prellis Biologics, a bioprinting technology company working to recreate tissues and organs for transplantation.

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[missy]

"
Editorials29 November 2022

Ongoing Need for Clinical Trials and Contemporary End Points for Outpatient COVID-19​

FREE
Todd C. Lee, MD, MPH and
David R. Boulware, MD, MPHAuthor, Article, and Disclosure Information
https://doi.org/10.7326/M22-3317


In their article, Qaseem and colleagues (1) present version 1 of the American College of Physicians' living, rapid practice points for the outpatient treatment of confirmed COVID-19. These practice points are based on a review by Sommer and colleagues (2) that included all trials on the Epistemonikos COVID-19 L·OVE Platform up to 4 April 2022. Although it is beyond the scope of this editorial to comment on the accuracy of that platform, we commend the authors for trying to summarize the rapidly evolving literature into clear practice points. They have also created a hierarchy of outcomes of interest, including death, recovery, hospitalization, and serious and nonserious adverse events. However, it is a testament to how rapidly things are changing that this living, rapid review is already more than 6 months out of date for many reasons.
With respect to molnupiravir (Practice Point 1), the recommendation for use is based on 2 randomized controlled trials involving 1637 participants. However, there are many more trials involving molnupiravir outside the MOVe-OUT program (3), and up to a dozen trials remain unpublished as of November 2022. Ignoring the major issue of publication bias, the real challenge with this recommendation comes from PANORAMIC (Platform Adaptive trial of NOvel antiviRals for eArly treatMent of covid-19 In the Community [4]) from the United Kingdom. PANORAMIC recruited 25 783 participants between 8 December 2021 and 27 April 2022—more than 10 times the number included in the Annals systematic review. It showed that molnupiravir was not effective at reducing hospitalization or death due to COVID-19 in high-risk outpatients, of whom 98% were vaccinated and who primarily had Omicron variant infections. Although PANORAMIC showed a time-to-recovery benefit, this open-label study is subject to bias for assessing time to recovery. Little evidence of time-to-recovery benefit was present in the original, double-blind, placebo-controlled MOVe-OUT trial (3). It is unlikely there will ever be a larger outpatient randomized COVID-19 trial.
With respect to Practice Points 2 (nirmatrelvir–ritonavir) and 3 (remdesivir), the major issue surrounds the populations that have been studied. The only published randomized controlled trials—EPIC-HR (Evaluation of Protease Inhibition for Covid-19 in High-Risk Patients [5]) (nirmatrelvir–ritonavir) and PINETREE (6) (remdesivir)—involved high-risk outpatients who were unvaccinated and were having their first COVID-19 illness, and these trials were conducted before Omicron. The standard-risk EPIC-SR trial (nirmatrelvir–ritonavir) was designed to involve low-risk unvaccinated and high-risk vaccinated patients, but EPIC-SR failed to meet the primary outcome (time to symptom improvement), and no statistical reduction in hospitalization occurred (7). To our knowledge, remdesivir has never been studied in randomized trials involving vaccinated patients, nor have monoclonal antibodies. Thus, a recommendation to use these products represents a substantial stretch from the actual evidence. In the Omicron era (and later), with natural and vaccine- or booster-derived immunity in most of the population, the effectiveness of these medicines remains unclear. The PANORAMIC platform is recruiting patients to nirmatrelvir–ritonavir at present and may provide the most insights (8).
Repurposed medicines, such as fluvoxamine (Practice Point 14), are recommended against (9), and metformin (10) is not addressed. Of concern is the 2-tiered definition of hospitalization being subtly used, where more than 24 hours of acute care is an acceptable definition of “hospitalization” for the EPIC-HR and MOVe-OUT trials (3, 5) but unallowable for repurposed agents. When fluvoxamine, 100 mg twice daily, is compared using the same definition of 24 hours of acute care or hospitalization, a modest benefit exists (9). Repurposed therapies remain highly relevant for low- and middle-income countries worldwide where expensive therapies are unavailable.
This editorial may feel nihilistic; however, the fact that hospitalization has become extremely uncommon compared with before vaccine availability is a testament to the successes of the public health campaigns that have fueled SARS-CoV-2 vaccination and boosting. Clinicians are still seeing COVID-19 and need guidance. Yet, the creation of guidelines may further erode the equipoise needed to perform the definitive trials that we truly require. Further, the widespread use of these agents in the absence of trials disincentivizes the manufacturers from conducting or allowing such trials. How do we move forward with generating the necessary evidence for a rational COVID-19 outpatient strategy, and how do we keep our recommendations up to date with a rapidly changing evidence base?
First, we really do need evidence generated for therapeutics in persons who have been multiply vaccinated or have recovered from COVID-19. Where the idea of receiving a placebo therapy may be unpalatable to some clinicians and patients, we can use multiple active agents with placebo controls. The ACTIV-6 (Accelerating COVID-19 Therapeutic Interventions and Vaccines) platform is one example of a rigorous active and placebo-controlled randomized trial that could potentially help answer these questions; however, the ACTIV-6 trial is scheduled to end enrollment in early 2023. Second, we will clearly need to move beyond dichotomized thinking surrounding end points. With hospitalization and death now rare in outpatients, trials powered on these outcomes become completely infeasible. What kind of end points should we consider for outpatient COVID-19 trials? The same type of end points that should inform clinical decision making and health care economics moving forward. With emergency departments and urgent care centers worldwide already under tremendous pressure in fall 2022, and with influenza and other respiratory viruses further driving health care use, a good argument could be made to include these types of care in any outcome. Preventing disease progression, resulting in reductions in emergency department visits or hospitalizations, is a clinical benefit to patients and a benefit to society in 2022 and beyond. People who are sick also want to feel better faster and avoid long-term sequelae of infection. Thus, time to recovery and the prevalence of persistent symptoms or “long COVID” become key components of outcome assessments for trials. Because care-seeking behavior and perception of symptoms are subject to bias due to knowledge of treatment assignment, blinded placebo or active control is essential. With these outcomes being collected, we can avoid dichotomized thinking and arrive at a bigger picture of what a medication's effects are in the current COVID-19 era.
Finally, we need a way to have evidence continually updated. The concept of living, rapid reviews is fantastically bold and innovative—but they challenge the traditional peer review and publishing model. Novel strategies to move evidence synthesis as close to publication as possible will be required.



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[missy]

"
China’s Covid crisis:

China said it would bolster vaccinations of senior citizens, a move regarded by health experts as crucial to reopening an economy that’s been stuck in a loop of “Covid zero” curbs. But it stopped short of announcing mandates that helped raise inoculation rates in other countries. The push comes days after protests erupted in cities from Beijing to Shanghai and even Kashgar as frustrated citizens took to the streets, urging an end to the curbs put in place by Xi Jinping. Rising infection rates and popular anger have combined to trigger a fresh crisis for a Communist government already facing disrupted businesses and slowing growth. Some Chinese officials however are striking a conciliatory tone in the face of the unrest, saying local authorities must respond to and resolve “reasonable” Covid requests from the public in a timely manner. —David E. Rovella
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"

November 30, 2022​

By Lauren Jackson

Good morning. The unrest that has swept across China is a rare public challenge to the world’s most powerful authoritarian government.​

Rare demonstrations​

The dissent was nearly unimaginable until a few days ago.

Protests against Covid lockdowns have rippled across China, among the most widespread there in decades. Some Chinese people, many of them young, are fed up with the government’s lockdowns, mandatory quarantines and mass testing, all part of the zero-Covid strategy intended to limit transmission of the virus. But few demonstrators shouted their frustration — they held up white pieces of paper instead.

These blank sheets illuminate the limits of criticism in China. In democracies, booming crowds and brazen signs are hallmarks of protest. But Chinese citizens risk being prosecuted for criticizing the government. The Communist Party under Xi Jinping, China’s leader, has cracked down on dissent, making even subtle acts of opposition perilous.

“These protests are absolutely extraordinary, especially in the era of Xi Jinping, who has really tightened controls on speech,” said Vivian Wang, a Times correspondent in Beijing who is covering the demonstrations there. “The white paper is an implicit criticism of that censorship.”

Standing at night in the dark, faces covered by masks, the protesters risk imprisonment by gathering at all. The empty paper serves as plausible deniability, a test to see how far they can go before being punished.

Today, I want to share photos and videos that illustrate how protesters are deploying unusual tactics to challenge the authorities.

Images of defiance​

The protests started after a building fire in the far western city of Urumqi killed at least 10 people, a tragedy many attributed to strict Covid lockdowns that confined people to their homes. People gathered in cities across the country to mourn the victims, including on Urumqi Road in Shanghai:

CHINATOPIX, via Associated Press

As anger spread across the country, the vigils morphed into protests against China’s zero-Covid policies. One gathering in Beijing began at an altar adorned in tribute to the fire’s victims and evolved into this demonstration:

Kevin Frayer/Getty Images

At the shifting, often leaderless scenes, even the demonstrators were uncertain about what to label the events, and some used blank signs to lean into the ambiguity. One Shanghai resident said that the initial purpose of the papers on Saturday was to signal to the police that those gathered were mourning silently. (White is a common color at Chinese funerals.)

“Chinese people are used to seeing their speech censored online, but you can’t censor people if they don’t say anything,” Vivian said. “They also don’t need to say anything. People know what they mean.”

The seemingly innocuous papers have forced government officials to determine what might be grounds for arrest, and some protesters used the sheets to mock the Communist Party’s predicament. Below, one paper on a wall at a gathering in Shanghai reads “I didn’t say anything” in Mandarin:

Hector Retamal/Agence France-Presse — Getty Images

Some protests were more direct. Crowds of people in Beijing and Shanghai, mainly in their 20s and 30s, marched and chanted for an end to the country’s three years of draconian Covid restrictions and demanded more rights. “We don’t want lockdowns, we want freedom!” they shouted. “Freedom of the press! Freedom of publishing!” Some in Shanghai went so far as to even call for Xi to step down, a rare and bold challenge.

Late Friday, videos circulated widely on the Chinese internet showing throngs of residents in Urumqi marching to a government building and chanting, “End lockdowns”:

Video Obtained By Reuters

As the protests continued into this week, Communist Party officials escalated their response, blanketing gathering sites with security personnel and vehicles. Here, you can see the police confronting a man as they tried to block a street in Shanghai:

Hector Retamal/Agence France-Presse — Getty Images

The authorities also went to homes to warn people against protesting and took some of them away for questioning. The specter of more aggressive crackdown is often enough to keep people from uniting to protest.

Censors scrubbed protest symbols and slogans from social media, and Chinese spam flooded Twitter to obscure news of the unrest. Some protest images slipped through, going viral outside the Chinese mainland. The hashtag “A4Revolution” — A4 is a reference to the size of the white pieces of paper — trended on Twitter over the weekend. At a vigil in Hong Kong, demonstrators held up blank paper in solidarity:

Anthony Kwan/Getty Images

What happens next remains uncertain. What is clear is that the protests have united many Chinese people in a rare display of civil unrest. Xi has remained silent, but the demonstrations have fractured the perception abroad that he exacts ironclad control over China’s citizens. Outside a university in Seoul, South Korea, hand-drawn posters criticized the Chinese government and begged for the world’s help — in the form of attention:

Anthony Wallace/Agence France-Presse — Getty Images "

 

[missy]

Flu related but including it here fyi

"

5 Things to Know About This Early Flu Season From CDC's Lynnette Brammer, MPH​

Lynnette Brammer, MPH

1. There's a lot of flu out there.​

According to the Centers for Disease Control and Prevention's FluView report, flu activity is elevated across the country, and flu hospitalization rates are the highest we have seen at this time in a decade. Hospitalization rates are highest among adults 65 years or older (18.6 per 100,000), followed by children younger than 5 years (13.6 per 100,000). Indicators used to track flu deaths are starting to rise. For communities that have not yet seen a lot of flu, it's coming. Now is a great time to get yourself, your staff, and your patients vaccinated.

2. There is more than one group of flu viruses spreading this season.​

H3N2 flu viruses have been most common so far, but an increasing proportion of H1N1 flu viruses has been detected recently. Flu vaccines protect against four different viruses, so vaccination efforts should continue, even among people who have already gotten flu this season, because they are vulnerable to infection with other flu viruses. Now is a great time to get yourself, your staff, and your patients vaccinated.

3. So far, laboratory data suggest that vaccination with this season's flu vaccines will trigger an immune response to most of the viruses we are seeing this season.​

Most of the flu viruses studied this season are genetically related to the vaccine viruses in this season's vaccines. Also, antibodies produced in ferrets against the current vaccine viruses have shown that antibodies from vaccination with this season's flu vaccines react well against most of the flu viruses so far this season. These data are promising as they relate to how well this season's flu vaccines will protect against flu. Now is a great time to get yourself, your staff, and your patients vaccinated.

4. Fewer people are vaccinated against flu this season.​

Fewer people are getting vaccinated this season. Data on adult flu vaccination show that more than 4 million fewer vaccines have been administered in pharmacies and doctors' offices this season compared with last. Especially worrisome for pregnant people, overall flu vaccination coverage at the end of October 2022 was nearly 12 percentage points lower compared with the end of October 2021 and more than 21 percentage points lower than at the end of October 2020. There are many people who are still unvaccinated and therefore more vulnerable to flu.

5. As a healthcare professional, your strong recommendation is a critical factor in whether your patients get an influenza vaccine.​

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[missy]

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Experts Debunk Claims From New Anti-Vax Documentary​

— "Died Suddenly," released on Twitter and Rumble, puts forth "blatant lies"​

by Michael DePeau-Wilson, Enterprise & Investigative Writer, MedPage Today November 30, 2022

A so-called documentary about COVID-19 vaccines prompted the latest social media effort by physicians to dispel dangerous medical misinformation.
Jonathan Laxton, MD, of the University of Manitoba Max Rady College of Medicine in Winnipeg, is one of those experts leading the effort to set the record straight. He called the claims made in the film -- titled "Died Suddenly" -- "blatant lies."
"My first impression was it's just basically over-the-top lies made to scare people away from getting the COVID-19 vaccine," Laxton told MedPage Today. "I think it's so over-the-top that it actually won't convince anybody who doesn't already believe it."

"Died Suddenly" was simultaneously released on Twitter and Rumble on November 21, and has been viewed more than 12 million times.
It features several embalmers and funeral directors who claim to be coming forward for the first time to share their concerns over supposedly unusual blood clots found in deceased individuals they prepared for burial. But the main individual featured in the film is Ryan Cole, MD, who has a history of promoting false claims about the COVID vaccines and cancer.
Katrine Wallace, PhD, an epidemiologist at the University of Illinois -- Chicago School of Public Health, debunked several of the claims from the film on her social media accounts, where she has become known for her work in pushing back against public health disinformation. She said the film follows a consistent pattern for disinformation campaigns.
"A lot of the tropes in this video are rehashed," Wallace told MedPage Today. "They just throw everything at the wall because something is going to appeal to someone's emotions."

'Science Is Not Done on Rumble'
The film focuses on two main claims against COVID-19 vaccines: extensive blood clots, and the sudden onset of cancer.
Eric Burnett, MD, of Columbia University's Irving Medical Center, said neither of those claims holds up to scrutiny.
"I see a lot of blood clots in the hospital," Burnett told MedPage Today. "Just looking at those blood clots from the movie, they look like very common postmortem blood clots, and I feel like it was just the shock and awe value of using these images of blood clots taken out of context to scare people."
One scene in the film that featured the removal of a large blood clot during a heart surgery was actually footage of a pulmonary embolectomy in 2019, which Burnett discovered via a Google search.
"To suggest that people are walking around with these massive clots filling up arteries and veins, without being symptomatic, without seeking medical attention for them, is a little hard to believe," Burnett said.

As for the cancer claims, Laxton said Cole started pushing that misinformation in April 2021, just one month after most people had access to the COVID-19 vaccines.
"[It's] biologically implausible for any carcinogens or cancer-causing agents to suddenly produce cancer within a month of exposure," he said.
Wallace emphasized that these easily disproven claims underlie one of the most confounding elements of disinformation films like this one.
"If this is happening, why do they not coordinate some effort to publish this case series of strange postmortem events so that the medical community can comment on it?" Wallace said. "If Dr. Ryan Cole really has seen hundreds of thousands of weird cases in his microscope, why is he not publishing those cases?"
Wallace noted that when cases of myocarditis with the mRNA vaccines and blood clots linked to the Johnson & Johnson vaccine appeared, researchers published case studies and the medical community reviewed and commented on them. If cases like the ones presented in the film exist, then Cole should follow the standard scientific practice to review that data with the wider medical community, she said.

"Science is not done on Rumble," Wallace said. "That's not how we do things."
Ongoing Fight Against Misinformation
Experts said the constant fight against misinformation and disinformation can be exhausting.
Wallace, who posts TikTok videos and Twitter threads debunking COVID misinformation, said she never intended to be a social media public health influencer. Nonetheless, she believes more researchers and healthcare professionals should consider sharing their perspectives with a wider audience.
"I do encourage other people to do it too just because there is no end to the energy on the anti-vaccine and medical misinformation side of things to create new lies, recycle old lies, and create new content [to] scare people," Wallace said. "The more voices we have that are sensible voices, the more we get the right information out there the better, because people believe this."
Burnett agreed that pushing back against false claims and misinformation is a necessary burden for medical professionals.

"What's more concerning for me is that there's actual physicians that they had on that documentary who were propagating this nonsense," he said. "If it's just some random person -- like your conspiracy theorist uncle -- who's saying this stuff, that's one thing, but when there's a doctor who has credentials, those credentials carry a lot of weight."
Having credentialed medical professionals pushing these false claims provides an air of legitimacy, Burnett said. It's becoming even more important to have conversations with patients about these claims, he added.
If more medical professionals speak out against false claims like those made in this video, it will make the efforts to push back easier for everyone and less of the burden would fall to a few self-selected individuals, Laxton said. Still, the best thing medical professionals can do is talk to their patients about these topics, he added.

"I think the [greatest] good healthcare workers can do is with individual patients," Laxton said. "Being aware of this information, and when you have a patient talking to you about it, you already have a trust relationship with them. That's very powerful to use that to help your patients out."

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  Michael DePeau-Wilson is a reporter on MedPage Today’s enterprise & investigative team. He covers psychiatry, long covid, and infectious diseases, among other relevant U.S. clinical news. Follow
  
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