May 2022 Coronavirus Updates

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The United States will surpass 1 million coronavirus deaths this week. On average, each of those deaths affected nine close relatives, not including close friends, neighbors or extended family members, leaving more than 9 million Americans mourning the loss of a loved one during the pandemic.

The Biden administration on Friday warned that a fall surge could infect up to 100 million people, my colleagues Yasmeen Abutaleb and Joel Achenbach reported. New omicron subvariants that appear to be very good at evading immunity could drive a sharp increase in cases in coming months. And a possible summer surge in the South could use up the nation’s supply of antivirals and tests just before the fall arrives.

Millions of people retired early during the pandemic, but they are returning to the workforce in droves now that many offices have reopened and restrictions have been lifted. An estimated 1.5 million retirees reentered the labor market in the past year, according to the Labor Department.

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COVID-19 Infection Has More Than 50
Long-Term Effects​

Carla Nieto Martínez
May 06, 2022




MADRID, Spain — Clinical experiences in approaching COVID-19 from different perspectives, results obtained by various therapeutic options and, above all, the challenges posed by a new healthcare reality — long COVID — were all the focus of a recent discussion at the 7th International Congress of the Spanish Society of Precision Health.
In this forum, titled Precision Health: A COVID-19 Professional Debate, Mayca González, MD, a specialist in microbiology and an expert in age management medicine at the University of Granada, reviewed the most recent data regarding long COVID. "According to the latest evidence, 9 out of 10 COVID-19 patients (87%) discharged from hospital experience at least one symptom 60 days after illness onset, with 32% reporting one or two symptoms and 55% presenting three or more. Additionally, more than 50% of symptomatic cases have at least one symptom of the disease 1 year after infection."
Another study found that 12.8% of the infected study participants continued to have dyspnea after 6 months, even in the absence of a pneumonia diagnosis, González added.
Research on this topic has also shed light on the main risk factors for developing long COVID. "First of all, gender, age, and even the number of symptoms" are risk factors, said González. "Therefore, women and people between 40 and 54 years of age are more likely to suffer from long COVID. It is also known that the more severe the acute illness, the greater the number of symptoms that appear after post-infection.

"Having a body mass index equal to or greater than 25, reporting three to seven symptoms of COVID-19 in the acute phase, and patients with more than five symptoms during the first week of the disease are factors associated with being prone to suffer from long COVID. All this sets up a health problem that will undoubtedly be a major challenge from now on."

González stressed that studies have shown that there are more than 50 long-term effects of COVID-19, the most prevalent being fatigue (58%), headache(44%), attention disorders (27%), and hair loss (25%).
Among all the research projects carried out on this topic, González highlighted a study published in January that, in her opinion, is one of the most relevant to date "because it delves into the pathophysiologic circumstances behind symptoms at all levels, something that we did not fully know until now.
"For example, it has been shown that dyspnea, hypoxia, fatigue, 'ground-glass' opacities, and pulmonary fibrosis are due to damage to the lung parenchyma [primarily] mediated by the virus and secondarily due to immunological microvascular damage. On the other hand, at a cardiovascular level, up to 20 cardiovascular conditions can occur 1 year after overcoming COVID-19. This allows us to foresee that these patients will be a significant demand on health systems in the coming years."

Microbiome and Vagus Nerve​

Regarding the digestive and intestinal system, González highlighted a hitherto unknown mechanism: the involvement of the vagus nerve and the intestinal microbiota.
"There are studies that suggest a pattern of persistent or recurrent viremia in some patients, causing a clinical evolution of nonspecific symptoms associated with personal limitations," she said. "This could lead us to think about the possibility that the virus would have a reservoir at this level. Along the same lines, research currently in progress points to a possible involvement of the vagus nerve as the cause of the manifestations of long COVID. We must not forget that this nerve connects the brain and the gastrointestinal tract, in addition to controlling heart rate, sweat production, and the gag reflex."
In her analysis of this pilot study carried out by a group of Spanish researchers, González commented that two thirds (22 of the 348 participants involved had at least one symptom suggestive of vagus nerve dysfunction. Upon further evaluation of these 228 patients, in the first 22 subjects with vagus nerve dysfunction, 20 were women with a median age of 44 years.
"The study also reflects that the most frequent vagus nerve dysfunction related symptoms were diarrhea(73%), tachycardia (59%), dizziness (45%), dysphagia(45%), and dysphonia (45%); 86% of the patients had three different vagus nerve dysfunction related symptoms. Six of the 22 patients displayed alteration of the vagus nerve in the neck shown by ultrasound, including both thickening of the nerve and mild inflammatory reactive changes," she noted.

Another important fact of this research was that 10 of the patients showed abnormal breathing patterns and reduced maximum inspiratory pressures, which, according to González, indicated the weakness of the respiratory muscles connected to the vagus nerve. "Seventy-two percent also had oropharyngeal dysphagia or difficulty swallowing, and eight patients showed reduced or impaired ability to move food from the esophagus to the stomach and acid reflux."

Prescription: Exercise​

At the same conference, Wilson Martínez, MD, a specialist in sports and exercise medicine, addressed the role of physical exercise in the recovery of people who have suffered from COVID-19. "It should be kept in mind that many patients with mild or severe COVID-19 do not fully recover and have a wide variety of chronic symptoms for months or weeks after infection that are often neurological, cognitive, or psychiatric in nature. This is what is known as post-COVID-19 syndrome, reported by between 10% and 20% of patients."

In his presentation, The Value of Exercise in the Post-COVID Patient, Martínez reviewed the most recent studies that show the link between exercise and the benefits for health in general and against SARS-CoV-2 and its consequences in particular. "In these investigations," he told the audience, "exerkines are discussed, understanding as such the substances that are produced or generated with the practice of physical activity (including hormones and metabolites) with healthy benefits at different levels. There is a varied repertoire of exerkines in the systemic circulation, and it is known that the higher the intensity and momentum with which exercise is performed, provided it is done properly, that these exerkines manifest in a more positive way."

In the context of COVID-19, Martínez explained this positive impact "taking into account that SARS-CoV-2 affects the angiotensin-converting enzyme-2 receptor, and this in turn involves the appearance of fibrosis, inflammation, vasoconstriction, reduced neurogenesis, and cardiovascular damage. This activation of a series of vascular signaling chains that occurs with exercise makes it possible to counteract a good number of the symptoms of the post-COVID-19 syndrome, acting in a certain sense like a polypill."

Specifying the potential benefits of exercise in post-COVID-19 syndrome, Martínez highlighted that there is an improvement in the psychological component, since it reduces stress, which translates into an improvement in mood and a feeling of well-being.

"At the neurological level, it stimulates brain plasticity, improves cognitive abilities, decreases allostatic load and optimizes sleep quality," he explained. "As for the cardiovascular system, angiogenesis occurs, improving the vascular system and cardiovascular function, lowering blood pressure, normalizing dysautonomia, and notably increasing mitochondrial biogenesis.


"In the respiratory system, it decreases dyspnea and improves oxygen consumption and lung function. In muscles, it improves exercise tolerance, increases muscle strength and muscle mass, with better intramuscular coordination. In relation to the immune system, it decreases inflammatory cytokines and increases anti-inflammatory cytokines, generally improving immune function," Martínez continued.

Strength Training Essential​

Martínez stressed that there is no known drug that produces all these benefits. "Unfortunately, we are not taught or used to prescribing exercise. Based on all this evidence, it is obvious that it should be incorporated into the prevention of and approach toward not only COVID-19 and post-COVID-19, but in general, for the care of cardiovascular and metabolic health, both to prevent diseases and as an adjuvant in many pathologies."

Regarding what type of activity is most recommended in these patients, Martínez pointed out that "there is sufficient evidence to suggest that adapted and supervised training with aerobic and strength endurance exercises can be an effective multisystemic therapy for post-COVID-19 syndrome."

In this sense, Martínez stressed the need to value the importance of strength training. "Although a good part of the population practices aerobic activity, the percentage drops when it comes to strength routines, especially among women, since they associate it with the risk of excessive bodybuilding. In the case of post-COVID-19, this training is essential, since one of the most worrying signs of this syndrome is the loss of muscle mass.

"A little more research is required in this field, but without a doubt, it is a perfect tool to counteract and manage the multiple signs and symptoms that persist after having suffered from COVID-19," Martínez concluded.

González and Martínez have disclosed no relevant financial relationships.

Follow Carla Nieto of Medscape Spanish edition on Twitter @carlanmartinez.
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Most COVID Transmission Is Still Asymptomatic​

— Some 60% of spread starts with those who have no symptoms, and that may be higher with Omicron​

by Jennifer Henderson, Enterprise & Investigative Writer, MedPage Today May 10, 2022

A cough or sneeze in the checkout line at the grocery store may elicit fear of COVID-19, but that maskless person quietly sitting next to you on the subway could pose just as much of a threat, public health experts say.
A significant proportion of COVID-19 transmission is asymptomatic or presymptomatic -- potentially as high as 60%, according to a 2021 JAMA Network Open modeling study.
That may be even higher now, as early reports have signaled a greater percentage of asymptomatic infections from Omicron than from previous variants. That could have a lot to do with higher baseline levels of immunity in the population when that variant hit, Helen Chu, MD, MPH, an infectious diseases physician at the University of Washington School of Medicine, told MedPage Today.

Chu said the more exposure to COVID-19 that an individual has -- either in terms of prior infection or vaccination -- the broader the immunity and the better the ability to control the virus. In such cases, an individual is more likely to be asymptomatic or have mild symptoms, she said.
Those with diminished viral loads may be less likely to transmit the disease, but they can still infect others, she said. And breakthrough cases can still carry high viral loads, as was observed in the Provincetown, Massachusetts outbreak in July 2021.
"Spaces that are not well ventilated, have large numbers of individuals, and places where people are speaking loudly or eating, those are the spaces that we should be most concerned about," Chu said.
Estimates of asymptomatic disease rates with COVID-19 -- the proportion who are infected but never manifest symptoms -- have ranged from about 25% to 40% throughout the pandemic, with a number of papers, including one in the Annals of Internal Medicine, coming in at about a third of cases.

There are no data yet on whether Omicron's subvariants, such as BA.2 and BA.4 and BA.5, cause more asymptomatic infections, Otto Yang, MD, an infectious diseases physician at the David Geffen School of Medicine at UCLA, told MedPage Today.
But he also noted that high levels of population immunity puts the U.S. in a "completely different situation from earlier when there weren't vaccines and few people had been infected."
Nonetheless, both Chu and Yang said the high rate of asymptomatic and presymptomatic transmission highlights the need for continued mitigation measures, especially to protect vulnerable populations such as children under 5 and the immunocompromised.
"We know what works, and I just find it puzzling that we aren't continuing to do the things that work when we know that there's long COVID, the under-fives are unvaccinated, and people can get repeatedly infected over time," Chu said. "We can't get to zero COVID, but it just surprises me that so many things have stopped, and in a time in which we have very little surveillance."

Yang also cautioned that continued transmission brings "more opportunity for new variants to develop, and the next variant could be more deadly for all we know."
Just last month, the CDC reported that as of February more than half of the U.S. population has been infected with COVID-19, including 75% of children and adolescents. About a third became newly seropositive since December 2021, when Omicron became predominant in the U.S.
CDC noted that seroprevalence can improve understanding of population-level incidence of COVID-19 because some cases are asymptomatic, not diagnosed, or not reported. However, it stated that seropositivity for antibodies produced in response to infection should not be interpreted as protection from future infection.
There also remains a concern about long COVID following infection, even one that occurs without acute symptoms, experts said.
"Given that community transmission levels are rising in most of the U.S., it is important we continue to layer mitigation measures to prevent further spread and exposure to the virus even if you are vaccinated," said Syra Madad, DHSc, MSc, of Harvard's Belfer Center for Science and International Affairs. "While the risk at the individual level may be low if you are not in the high-risk category, and we have more tools to manage the disease including antivirals, the risk to the overall community is still high."
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"Infectious disease

Moderna's COVID Vaccine Holds Up for Kids 6-11 Years​

— Interim results get peer-reviewed journal treatment ahead of potential EUA​

by Molly Walker, Deputy Managing Editor, MedPage Today May 11, 2022

Moderna's COVID vaccine (Spikevax) was safe, effective, and produced an immune response in children ages 6-11, an interim analysis of a phase II/III trial found.
Two 50 μg doses of vaccine -- half the dose of Moderna's primary series for adults -- administered 28 days apart produced a non-inferior immune response in children ages 6-11 as in adults ages 18-25, reported Sabine Schnyder Ghamloush, MD, of Moderna in Cambridge, Massachusetts, and colleagues.

In a modified intention-to-treat population, estimated vaccine efficacy (VE) was 88.0% (95% CI 70.0-95. against symptomatic COVID (primarily the Delta variant) at 14 days or more following the first injection, the authors wrote in the New England Journal of Medicine.
The manufacturer first shared top-line data from this trial in October 2021, although no efficacy results were reported at that time. More recently, Moderna announced it would be filing for emergency use authorization (EUA) for this vaccine and its vaccine for children 6 months to 5 years of age (two 25 μg doses).
Ghamloush's group shared the results of the KidCOVE trial, which took place in the U.S. and Canada, and was comprised of three age cohorts: 6-11 years, 2-5 years, and 6 months to 23 months. Part 1 was a dose selection study where 751 children received either two 50 μg or 100 μg doses of the vaccine, and the manufacturer selected the 50 μg dose moving forward.

In part 2, children were assigned 3:1 to receive either two injections of vaccine or placebo. VE was based on incidence of COVID infection among all participants without serologic or virologic evidence of SARS-CoV-2 injection at baseline, and who received at least one injection. Symptomatic COVID was defined as a positive PCR test plus one systemic or respiratory symptom.
From March to August 2021, 4,016 participants were enrolled in part 2 of the trial. Overall, 2,998 participants in the vaccine group and 973 participants in the placebo group received two injections. Mean age of participants in the safety cohort was about 9 years, 51% were boys, and two-thirds were white. About 20% had obesity.
Similar to the adult trials, solicited systemic adverse events (AEs) after the second dose were higher in the vaccine group than in the placebo group (78% vs 50%, respectively). The most common AEs were headache and fatigue, though chills and fever were higher following the second injection compared with the first in the vaccine group. The majority of AEs were grade 1 or 2, but there was a higher proportion of grade 3 AEs in the vaccine group than in the placebo group (12% vs 1%).

Serious AEs in the vaccine group included appendicitis, cellulitis, and orbital cellulitis, but were considered to be unrelated to the vaccine, the authors said. There were no cases of anaphylaxis, multi-system inflammatory syndrome in children (MIS-C), myocarditis, or pericarditis attributable to the vaccine or placebo as of the cut-off date, the researchers wrote.
Ghamloush's team added that at least 99% of both children and young adults had serologic responses a month following the second injection, which met the non-inferiority success criterion.
There were seven COVID cases in the vaccine group and 18 cases in the placebo group at least 14 days after the first injection. Estimated VE against SARS-CoV-2 infection was 74.0% (95% CI 57.9-84.1), regardless of symptoms, and estimated VE against asymptomatic infection specifically was 62.5% (95% CI 30.9-79.4).
The investigators added that the populations were too small and the time period too short to calculate VE after two injections in the per-protocol population.
Given that the trial occurred during the Delta wave, the authors concluded that the "findings suggest that this vaccine provides a protective benefit for children against variants of concern."
The trial is ongoing in both this population and younger children, the team noted.

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COVID Tests Recalled; Hospitals Get Safety Grades; 'No End in Sight' in Shanghai​

— A daily roundup of news on COVID-19 and the rest of medicine​

by Judy George, Senior Staff Writer, MedPage Today May 11, 2022

Skip the Skippack Medical Lab SARS-CoV-2 antigen rapid test (colloidal gold), the FDA advised: the test is not authorized, cleared, or approved by the agency and is being recalled.
And the Accula SARS-CoV-2 PCR test by Mesa Biotech has been recalled due to contaminated test materials at the manufacturing site that could lead to false positive findings, the agency warned.

The FDA approved a new indication for baricitinib (Olumiant) to treat COVID-19 in hospitalized adults needing supplemental oxygen, mechanical ventilation, or extracorporeal membrane oxygenation, drugmaker Eli Lilly announced. The drug was previously authorized for emergency use in COVID-19.
Telehealth may deliver more doses of Pfizer's oral antiviralnirmatrelvir/ritonavir (Paxlovid) to COVID-19 patients. (STAT)
The Leapfrog Group issued updated safety grades for nearly 3,000 hospitals: these hospitals flunked and these earned straight As. (Becker's Hospital Review)
As of Wednesday at 8:00 a.m. EDT, the unofficial U.S. COVID toll was 82,092,405 cases and 999,742 deaths, increases of 80,891 and 267, respectively, from this time yesterday morning.
A spike of 500 COVID cases at Johns Hopkins University in Baltimore has led some students to ask for online exams. (Washington Post)
With cases rapidly rising in the city, Baltimore's health commissioner advised people to resume indoor masking. (Baltimore Sun)
Shanghai's zero-COVID lockdowns have left thousands without income or food sleeping in the streets. (Wall Street Journal)

The head of the World Health Organization said China's zero-tolerance policy is not sustainable, given what's known about the virus. (Reuters)
While a modeling study suggested that moving away from a zero-COVID policy in China could lead to an Omicron wave causing 1.55 million deaths. (Nature Medicine)
Meanwhile, tensions in Shanghai rise: "We had thought the lockdown could be eased this month, but now there's no end in sight again," said one resident. (The Guardian)
Two Senate Democrats are willing to give Republicans a vote on extending pandemic-era border restrictions to get the stalled $10 billion COVID bill moving. (Politico)
The number of people who say they're definitely not getting vaccinated hasn't shifted in over a year. (NPR)
Emergent BioSolutions concealed evidence last year from FDA inspectors of a potential contamination problem with batches of COVID vaccines before they were destroyed, a House panel said. (Washington Post)

With COVID hospitalization rates stabilizing, travel nurses are seeing lucrative contracts vanish. (NBC News)
Ticks are spreading throughout the U.S. and bringing new diseases with them. (Wired)
Drinking espresso was linked with serum total cholesterol, more so for menthan women. (Open Heart)
The U.S. Preventive Services Task Force affirmed its recommendation against screening for chronic obstructive pulmonary disease in asymptomatic adults. (JAMA)
Male testis tissue that was cryopreserved and implanted after more than 20 years was able to make viable sperm, a rodent study showed. (PLOS Biology)
The NeuroStar transcranial magnetic stimulation system received FDA clearance as adjunctive treatment for obsessive compulsive disorder, Neuronetics said. The device previously was cleared to treat major depressive disorder.
Texas abortion laws may deter some providers from offering optimal miscarriage treatment. (NPR)
Google searches for "vasectomy" have jumped in Texas. (Houston Chronicle)
Analyses of lung specimens from the early 1900s in Europe suggest the current seasonal H1N1 virus may have descended from the 1918 Spanish flu. (Nature Communications)
The phase III trial of the seaweed-derived drug oligomannate from Green Valley Pharmaceuticals, conditionally approved to treat Alzheimer's disease in China, has stopped. (Endpoints News)
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"Do COVID Vaccines Stave Off New Medical Conditions?​

— Large study finds breakthrough cases linked with lower risk of diabetes, hypertension diagnoses​

by Molly Walker, Deputy Managing Editor, MedPage Today May 9, 2022

Risks of long COVID symptoms and the incidence of new onset hypertension, diabetes, and heart disease were lower among vaccinated patients with breakthrough infection versus those with COVID who were unvaccinated, a large analysis of medical records in the U.S. suggested.
Compared to those who were unvaccinated, relative risks were 0.33 for hypertension (95% CI 0.26-0.42), 0.28 for diabetes (95% CI 0.20-0.3, and 0.35 for heart disease (95% CI 0.29-0.44) at 90 days following COVID diagnosis for the vaccinated group, reported Grace McComsey, MD, of Case Western Reserve University in Cleveland, Ohio, and colleagues.

Moreover, risk of death 90 days later was significantly lower as well (RR 0.21, 95% CI 0.16-0.27), the authors wrote in Open Forum Infectious Diseases.
"Differences in both 28 and 90-day risk between the vaccine and no-vaccine cohorts were observed for each outcome and there was enough evidence ... to suggest that these differences were attributed to the vaccine," they wrote.
McComsey and colleagues examined retrospective data from TriNetX, described as "a large national health research network" from 57 U.S. centers. Participants were adults with SARS-CoV-2, confirmed by PCR testing, who sought care from September 2020 to December 2021. They were stratified into two groups: vaccinated with breakthrough infection and unvaccinated patients. Long COVID, or "post-acute sequelae of COVID" was defined as new, continuing, or recurrent symptoms occurring 4 or more weeks after initial COVID infection. Patients were also matched by baseline comorbidities.
Overall, 1,578,719 patients with confirmed COVID were identified, with 25,225 of those (1.6%) having documented COVID vaccination. In the vaccine cohort, average age was about 55, about 60% were women, and 68% were white. At baseline, 47% had hypertension, 23% had diabetes, and 13% had chronic kidney disease. In the unvaccinated cohort, average age was 43 years, 56% were women, and 62% were white. A lower proportion also had pre-existing conditions (28% with hypertension, 14% with diabetes, and 6% with chronic kidney disease), but none of these differences were significant after matching.

At 90 days following COVID diagnosis, the authors found risk of new or persistent outcomes was lower in the vaccine cohort versus the unvaccinated cohort. Incidences (per 1,000) in the vaccinated compared to the unvaccinated cohort, respectively, were 7.19 versus 20.26 for heart disease, 6.45 versus 25.53 for mental disorders, 6.42 versus 19.59 for hypertension, and 2.69 versus 9.69 for diabetes.
The vaccinated cohort also saw lower risks of new respiratory symptoms (RR 0.54, 95% CI 0.50-0.57), headache (RR 0.39, 95% CI 0.34-0.45), fatigue (RR 0.48, 95% CI 0.43-0.52), body ache (RR 0.34, 95% CI 0.28-0.42), and diarrhea or constipation (RR 0.44, 95% CI 0.40-0.49) at 90 days.
The authors noted that in addition to the usual post-COVID symptoms, such as headaches, fatigue, body aches, and respiratory and gastrointestinal symptoms, they found that vaccination was associated with a lower risk of new-onset diseases such as hypertension, diabetes, heart disease, and mental disorders. They "very carefully captured new outcomes" occurring after COVID, not merely pre-existing medical conditions, the group maintained.

"We hypothesize that [vaccination's] effect on reducing the inflammatory responses during the acute phase does also explain the lower rates of all [post-acute sequelae of SARS-CoV-2] outcomes observed in our study among the vaccinated group," wrote McComsey and coauthors.
Limitations to the data include use of electronic medical records, that true prevalence of these post-COVID symptoms is unknown, as many asymptomatic patients were not tested for the virus, and that immunization status may be a source of bias, as those who were likely to be vaccinated may have been more likely to seek or receive medical attention.
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Neuropsychiatric Risks of COVID: New Data​

Megan Brooks
May 11, 2022




The neuropsychiatric ramifications of severe COVID-19 infection appear to be no different than for other severe acute respiratory infections (SARI).
Results of a large study showed risks of new neuropsychiatric illness were significantly and similarly increased in adults surviving either severe COVID-19 infection or other SARI, compared with the general population.
This suggests that disease severity, rather than pathogen, is the most relevant factor in new-onset neuropsychiatric illness, the investigators note.
The risk of new-onset neuropsychological illness after severe COVID-19 infection are "substantial, but similar to those after other severe respiratory infections," study investigator Peter Watkinson, MD, Nuffield Department of Clinical Neurosciences, University of Oxford, and John Radcliffe Hospital, Oxford, England, told Medscape Medical News.

"Both for those providing and commissioning services, neuropsychological sequelae need to be considered after all severe respiratory infections, rather than only following severe COVID-19 disease," Watkinson said.

The study was published online May 11 in JAMA Psychiatry.

Significant Mental Health Burden​

Research has shown a significant burden of neuropsychological illness after severe COVID-19 infection. However, it's unclear how this risk compares to SARI.

To investigate, Watkinson and colleagues evaluated electronic health record (EHR) data on more than 8.3 million adults, including 16,679 (0.02%) who survived a hospital admission for SARI and 32,525 (0.03%) who survived a hospital stay for COVID-19.
Compared with the remaining population, risks of new anxiety disorder, dementia, psychotic disorder, depression, and bipolar disorder diagnoses were significantly and similarly increased in adults surviving hospitalization for either COVID-19 or SARI.

Diagnosis	SARI HR (95% CI)	COVID-19 HR (95% CI)
Anxiety	1.86 (1.56 - 2.21)	2.36 (2.03 - 2.74)
Dementia	2.55 (2.17 - 3.00)	2.63 (2.21 - 3.14)
Psychotic disorder	3.63 (1.88 - 7.00)	3.05 (1.58 - 5.90)
Depression	3.46 (221 - 5.40)	1.95 (1.05 - 3.65)
Bipolar disorder	2.26 (1.25 - 4.0	2.26 (1.25 - 4.07)

Compared with the wider population, survivors of severe SARI or COVID-19 were also at increased risk of starting treatment with antidepressants, hypnotics/anxiolytics, or antipsychotics.
When comparing survivors of SARI hospitalization to survivors of COVID-19 hospitalization, no significant differences were observed in the postdischarge rates of new-onset anxiety disorder, dementia, depression, or bipolar affective disorder.


The SARI and COVID groups also did not differ in terms of their postdischarge risks of antidepressant or hypnotic/anxiolytic use, but the COVID survivors had a 20% lower risk of starting an antipsychotic.


"In this cohort study, SARI were found to be associated with significant postacute neuropsychiatric morbidity, for which COVID-19 is not distinctly different," Watkinson and colleagues write.


"These results may help refine our understanding of the post-severe COVID-19 phenotype and may inform post-discharge support for patients requiring hospital-based and intensive care for SARI regardless of causative pathogen," they write.

Caveats, Cautionary Notes​

Kevin McConway, PhD, emeritus professor of applied statistics at the Open University in Milton Keynes, England, described the study as "impressive." However, he pointed out that the study's observational design is a limitation.


"One can never be absolutely certain about the interpretation of findings of an observational study. What the research can't tell us is what caused the increased psychiatric risks for people hospitalized with COVID-19 or some other serious respiratory disease," McConway said.

"It can't tell us what might happen in the future, when, we all hope, many fewer are being hospitalized with COVID-19 than was the case in those first two waves, and the current backlog of provision of some health services has decreased," he added.

"So we can't just say that, in general, serious COVID-19 has much the same neuropsychiatric consequences as other very serious respiratory illness. Maybe it does, maybe it doesn't," McConway cautioned.

Max Taquet, PhD, with the University of Oxford, noted that the study is limited to hospitalized adult patients, leaving open the question of risk in nonhospitalized individuals — which is the overwhelming majority of patients with COVID-19 — nor in children.

Whether the neuropsychiatric risks have remained the same since the emergence of the Omicron variant also remains "an open question since all patients in this study were diagnosed before July 2021," Taquet said in statement.

The study was funded by the Wellcome Trust, the John Fell Oxford University Press Research Fund, the Oxford Wellcome Institutional Strategic Support Fund and Cancer Research UK, through the Cancer Research UK Oxford Centre. Watkinson disclosed grants from the National Institute for Health Research and Sensyne Health outside the submitted work; and serving as chief medical officer for Sensyne Health prior to this work, as well as holding shares in the company. McConway is a trustee of the UK Science Media Centre and a member of its advisory committee. His comments were provided in his capacity as an independent professional statistician. Taquet has worked on similar studies trying to identify, quantify, and specify the neurological and psychiatric consequences of COVID-19.

JAMA Psychiatry. Published online May 11, 2022. Full text

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Breakthrough COVID Deaths Increasing in US​

Carolyn Crist
May 11, 2022

Breakthrough deaths are making up a larger portion of those who have died from COVID-19, according to a new analysis from ABC News.
That means more COVID-19 deaths are occurring among those who are vaccinated against the coronavirus. But public health experts say that should be expected as more Americans reach full vaccination status.
"These data should not be interpreted as vaccines not working," John Brownstein, PhD, an epidemiologist at Boston Children’s Hospital, told ABC News.

"In fact, these real-world analyses continue to reaffirm the incredible protection these vaccines afford, especially when up to date with boosters," he said.

In August 2021, about 19% of COVID-19 deaths occurred among vaccinated people. Six months later, by February 2022, the proportion had increased to more than 40%.
What’s more, about 1.1% of COVID-19 deaths occurred among Americans who were fully vaccinated and boosted in September 2021. By February 2022, that increased to about 25%.
Even so, in February, unvaccinated adults were 10 times more likely to die of COVID-19, compared to vaccinated adults, and five more times likely to require hospitalization, ABC News reported. Compared to fully vaccinated and boosted adults, unvaccinated people were about 20 times more likely to die of COVID-19 and seven times more likely to require hospitalization.
As of Wednesday, more than 220 million Americans had been fully vaccinated, according to the latest CDC data, and 101 million had received their first booster shot. About 91.5 million eligible Americans — about half of those who are now eligible — hadn’t gotten their first booster shot.
Breakthrough deaths appear to be rising as a growing proportion of older Americans are hospitalized for COVID-19, ABC News reported. After older adults had received their vaccinations last spring and summer, the number of hospital patients over age 65 dropped to a pandemic low. But the average age has risen again throughout the Omicron variant and subvariant waves.
More than 90% of seniors have been fully vaccinated, according to CDC data, and about 69% have received a booster shot. Even with high vaccination rates, about 73% of COVID-19 deaths were among ages 65 and older during the Omicron surge, ABC News reported.
Vaccines and booster shots continue to provide significant protection against severe disease, hospitalization, and death, Brownstein said. But waning immunity from vaccines and previous infections, along with variants containing new mutations, can reduce protection against a coronavirus infection.

Older adults and high-risk Americans should receive more doses, Brownstein said. About 10.5 million people in the U.S. have received their second booster shot, according to CDC data.

All Americans over the age of 50 are eligible for a second booster dose, as well as immunocompromised people over age 12 and those who received two doses of the Johnson & Johnson vaccine.

"This trend in increased risk among the elderly further supports the need for community-wide immunization," Brownstein said. "Older populations, especially those with underlying conditions, continue to be at great risk for severe complications, especially as immunity wanes."

Sources:

ABC News: "Breakthrough deaths comprise increasing proportion of those who died from COVID-19."

CDC: "COVID Data Tracker: COVID-19 Vaccinations in the United States."
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Getting Covid. Again. And again.​

After the omicron surge this winter, there was hope that all those infections would at least mean that Covid would lay low for a while and give us all a bit of a break. It’s starting to seem like that might not be the case. Once again, infections are steadily rising in the US. Some people are catching Covid for a second, third or even a fourth time. Having recently gotten ill seems to no longer be a guarantee you’re protected against Covid for any length of time. Early studies have suggested that the newer omicron sublineages can actually evade not just the antibodies of previous variants like delta, but even the antibodies of previous versions of omicron. "The reality is that things are really not going well at the moment,” Jake Lemieux, an infectious disease doctor at Massachusetts General Hospital, said at a Harvard Medical School Covid briefing on Tuesday. “We all thought that we were in for a reprieve after the devastating omicron wave. And that was clearly the case until a few weeks ago.” For some people, that thin red line is becoming a familiar sight. Source: Bloomberg There’s a lot we don’t know about these reinfections — and what we don’t know makes it all the more difficult to gauge the state of the pandemic more generally. (Read the full story here.) It’s unclear how frequently reinfections occur or which variants people are getting reinfected with. That’s just not currently part of the Centers for Disease Control and Prevention’s Covid data collection. A handful of state health departments have taken to diligently monitoring the repeat cases, but even they say reinfections are definitely being undercounted. Still, their data highlights something important: Reinfections are becoming more common. The Colorado State Health Department, for example, has recorded more than 44,000 reinfections throughout the pandemic — 82% of which have occurred since omicron became the dominant variant in December. Reinfections are more common among the unvaccinated, but more than a third have happened to people who have completed their initial two-dose vaccine series, according to the data. Over 16% of reinfections in Colorado have been in people with at least one booster dose. Data from the North Carolina Department of Health and Human Services show reinfections in the state have been increasing since late March. Reinfections currently make up 8% of the state’s total infections for the week ending April 30. Repeat infections have been on the rise in Indiana, too, according to data, where they account for more than 12% of total cases, and in Idaho, where they accounted for 18.5% of cases in the first quarter of 2022. A report from Washington state published Wednesday shows that some reinfections are also leading to hospitalization. The age group most likely to get reinfected is 18 to 34, but people 65 and older are the most likely to get hospitalized after reinfection, the data show. “It feels like the first time in two years that no matter if someone is really careful and does everything right, it won’t be surprising if they end up getting Covid,” Bob Wachter, the chair of medicine at University of California, San Francisco, told me. “We’re unquestionably in a surge.” — Madison Muller "

 

[missy]

Tracking Covid risk in the air​ May 22, 2022

Over the past month I have been carrying around a palm-sized, $150 carbon-dioxide monitor to assess how risky spaces are during the latest omicron surge. I took the device with me to a family Passover seder in Illinois, wine tastings in Oregon’s Willamette Valley and the annual New Orleans Jazz & Heritage Festival. And I learned that, most of the time, the places I went were poorly ventilated. Carbon-dioxide monitors can assess how Covid-risky a space is because they help tell you whether you’re breathing in clean air. They measure the concentration of carbon dioxide, which people exhale when they breathe, along with other things like, potentially, virus particles. The more well-ventilated a space, the lower the reading on my monitor's screen — meaning not only less carbon dioxide but also less of the stuff like Covid that might make people sick. A carbon dioxide monitor takes a reading of the air at JazzFest. Source: Emma Court/Bloomberg One place I didn’t expect this to be an issue was airplanes, because you hear so much about their top-of-the-line air quality systems. But in fact, some of the highest carbon dioxide readings on my travels were taken on flights, specifically during the boarding process. It turns out that during boarding and deplaning, air systems aren’t typically running. Those periods are risky because people are mingling more than they do during a flight, says Joe Allen, an associate professor at the Harvard T.H. Chan School of Public Health who carries around his own CO2 monitor. “We’ve been warning about this,” Allen says. Fresh air is important for our health in ways that go well beyond Covid, but it’s also largely invisible. Carbon-dioxide monitors can change that. But they also aren’t perfect, and can’t tell you everything. Carrying the CO2 monitor with me didn’t, for instance, stop me from getting Covid. You can read more about that in our full story here. — Emma Court

 

[missy]

"

Does heat kill coronavirus (COVID-19)? Can it disinfect face masks and packages?​

Latest Update
Omicron Lasts on Surfaces
Last Updated: 05/16/2022

Answer:​

If used properly, moderate or high heat can be used to "kill" coronavirus, inactivating the virus so that it is no longer infectious. However, in many cases this may be more time-consuming than other methods such as chemical disinfection (with disinfecting wipes or sprays) and there is often no need to disinfect packaging at all if you can just remove the packaging, dispose of it (preferably by recycling), and then disinfect your hands by washing with soap and warm water or using another disinfection method.

Very low risk of COVID-19 infection from food and food packaging

The FDA has reviewed the current evidence and affirmed that "the risk is exceedingly low for transmission of SARS-CoV-2 to humans via food and food packaging." (FDA 2021). However, the FDA does note "...if you wish, you can wipe down product packaging and allow it to air dry, as an extra precaution," and provides tips for grocery shopping and safe food handling during the pandemic.

Heating kills coronavirus

Heat is very effective at sanitizing and disinfecting objects from coronavirus. If anyone tells you that coronavirus is resistant to heat, they're wrong. In fact, the SARS-CoV-2 virus that causes COVID-19 may be even more sensitive to heat than the earlier SARS-CoV virus. Experiments done in China in 2002 with SARS-CoV in culture medium (Duan, Biomed Env Sci 2003) showed that coronavirus became undetectable after 30 minutes when heated to a temperature of 167°F, but recent tests with SARS-CoV-2 in Hong Kong showed that it became undetectable after just five minutes at only 158°F (70°C). The time required to kill SARS-CoV-2 increased as the temperature was reduced, such that the time by which it was undetectable increased to 30 minutes at 132°F (56°C), two days at 98.6°F (37°C), and two weeks at 71.6°F (22°C). At 39°F (4°C) the virus remained detectable at two weeks when the experiment ended (Chin, Lancet 2020).

This suggests, for example, that if you purchase take-out food and wish to disinfect the container itself of coronavirus (as well as keep your food warm), you can simply place the container in a warm oven or warming drawer for a period of time, such as at 150°F (65°C) for 60 minutes (giving it ample time to heat up) to disinfect it. Just be sure it is not directly exposed to a heating element so as not to pose a fire hazard. Most plastic and paper containers are stable for short periods at up to 200°F (93°C).

Theoretically, heating a face mask this way may also disinfect it. Moist heat may be better than dry heat. One way to do this, as explained by the Department of Homeland Security Science and Technology Directorate (S&T), is to use a multicooker or electric pressure cooker that has a sous vide function or equivalent capability to set the time to 30 minutes and the temperature to 149°F (65°C), placing the mask on a rack to keep the mask out of the water (binder clips can be used to elevate the rack). The bottom of the pot should be covered with ½ inch of water, and the mask should be placed in a paper bag and the bag stapled closed, before placing on the rack. Up to three masks can be nestled together in one bag. When the cycle is over, the masks should be removed and allowed to dry (about one hour should be sufficient). A complete instructional video is available on the Department of Homeland Security S & T website. A study by researchers at Stanford University found that heating N95 masks (known as respirators) at 167°F (75°C) for 30 minutes (at 85% relative humidity) did not compromise the masks, even after 20 cycles — although these researchers have subsequently cautioned that contaminated masks should not be brought into homes. (If you use an N95 respirator, you may want to watch a video from the New England Journal of Medicine that instructs health care workers on how to properly put on, take off, and test the fit of such masks and other personal protective equipment.)

Another way to use an electric cooker to decontaminate N-95 respirators is to place a towel inside the cooking pot with the respirator laying on the towel (avoiding direct contact between any part of the respirator and the pot) and heating the mask to 212°F (100°C) for 50 minutes -- which requires heating the pot to about 250°F to 300°F (120° to 150°C). The University of Illinois researchers who developed this process (and uploaded a demonstration video on YouTube) found that respirator filtration and fit were not compromised after 20 cycles of this dry heat treatment (Oh, Env Sci Tech Letters 2020).

A U.S. government laboratory heated SARS-CoV-2-contaminated N95 mask material in a dry oven at 158°F (70°C) and found that virus was undetectable at 50 minutes, but they also found two cycles of this dry heating caused the material to lose some integrity (possibly suggesting that some humidity during heating may be beneficial) (Fischer, medRxiv, 2020 — preprint).

These same government researchers found that ultraviolet light (UVC at 0.005 mW/cm2) could achieve the same antiviral effect as heat with less impact on mask integrity but required about 60 minutes and this did not factor in additional time to properly irradiate curved surfaces of the mask. They determined that vaporized hydrogen peroxide(requiring a special, enclosed incubator) was the fastest and least damaging method of decontamination, taking only 10 minutes. Spraying ethanol to saturate the mask material was a bit faster at deactivating virus but caused the greatest reduction in mask integrity (Fischer, medRxiv, 2020 — preprint).

You should not soak N95 or surgical masks in disinfectants such as alcohol or other liquids as this can compromise their electrostatic charge (reducing their filtering capability) and fit (Interview with R. Shaffer, JN Learning 2020). Researchers at Stanford University found that immersing N-95 mask material in 75% ethanol or spraying with a household chlorine bleach solution (2% sodium hypochlorite) decreased the filtration efficiency (due to loss of electrostatic charge) to unacceptable levels after just one treatment, from about 96% to 56% and 73%, respectively.

Steam treatment (material placed 6 inches above a glass containing boiling water for 10 minutes) was effective if used once, but after five treatments filtration efficiency fell below acceptable levels (85%) (Liao, ACS Nano 2020).

Note that washing cloth face masks in a washing machine should suffice to disinfect them, according to the CDC. The agency also cautions not to touch your eyes, nose, and mouth when removing cloth coverings, and to wash hands immediately after removing.

Coronavirus lasts longer on certain surfaces, particularly surgical masks! And Omicron lasts even longer.

The Hong Kong researchers noted above also placed a small amount of the SARS-CoV-2 on a variety of surfaces at room temperature (at 65% relative humidity) to see how long the virus would last before becoming undetectable. On tissue paper and regular paper it became undetectable within just 3 hours. On cloth and on paper money, it lasted 2 days. Surprisingly and disturbingly, it lasted longest on the outer layer of a surgical mask: Virus was detectable on the mask at day 7 (although at only 0.1% of its original level), which was also how long it lasted on plastic and stainless steel. Interestingly, a subsequent study by the same researchers showed that the Omicron BA.1 variant can persist on surfaces for even longer than the original strain. Sign in for details.

Microbiologists who placed coronavirus samples on the interior surfaces of a car, including carpeting and plastic parts, found that viral concentrations were reduced by greater than 99% within 15 minutes when the interior air was heated to 133°F (56°C), raising surface temperatures to 120°F (Unpublished study reported in The New York Times, May 30, 2020).

Don't directly refrigerate or freeze — it keeps the virus infectious

Studies with coronaviruses noted above and by others (Kampf, J Hosp Infect 2020) indicate that cold temperatures help preserve it and keep it infectious. Consequently, you should not place a recently purchased food container directly into a refrigerator or freezer and you should not "quarantine" a recently received package in a cold cellar or cold garage, as this will preserve coronavirus and could keep it infectious for days. Freezing can preserve coronavirus for years (WHO, COVID-19 Situation Report 32, 2020). The good news is that the coronavirus won't linger quite as long on surfaces and in the air in warm summer weather as it does in the winter, although this won't make much of a difference should an infected person cough near you.

How effective are disinfectants against coronavirus?

The Hong Kong researchers also showed that common disinfectants were effective in killing SARS-CoV-2. The virus was undetectable after 5 minutes of exposure to household bleach (at a concentration of 1:49 or 1:99), ethanol (70%), povidone-iodine (7.5%), chloroxylenol (0.05%), chlorhexidine (0.05%) and benzalkonium chloride (0.1%). Fifteen minutes were required for the virus to be undetectable when exposed to a hand soap solution. The researchers only checked at 5 and 15 minutes, so it is possible that less time is necessary, but as we don't know the minimum time for disinfection, it would seem prudent to allow disinfectants a few minutes on surfaces before wiping them off. For the latest list of disinfectants that meet the U.S. EPA's criteria for use against SARS-CoV-2, see the EPA's "List N." There is a search box to quickly look up a product or ingredient and you should view the "Contact Time" to see how long each disinfectant must remain wet on a surface. The list includes ready-to-use liquids, dilutable liquids, and wipes. (Note that products on List N have not been tested specifically for SARS-CoV-2, but have demonstrated efficacy against a similar coronavirus or a harder to kill virus.)

Be careful when using and storing chemical disinfectants

Calls to poison control centers increased sharply in March 2020 due to disinfectants (CDC, 2020). Cases have included a woman who developed difficulty breathing after mixing 10% bleach with vinegar and water to wash her produce and a child was found unresponsive after consuming ethanol-based hand sanitizer. The CDC advises that "users should always read and follow directions on the label, only use water at room temperature for dilution (unless stated otherwise on the label), avoid mixing chemical products, wear eye and skin protection, ensure adequate ventilation, and store chemicals out of the reach of children."

Hand sanitizer

The importance of proper hand hygiene in potentially reducing the spread of COVID-19 was highlighted by a study that showed that SARS-CoV-2, the virus that causes COVID-19, can survive on skin for up to 9 hours, which is longer than the 1.8 hours for a flu virus (Hirose, Clin Infect Dis 2020). Keep in mind, however, that contact transmission is not considered to be the primary method of COVID-19 transmission — virus-containing droplets in the air are the primary route, and the "infectious dose" of SARS-CoV-2 needed to spread COVID-19 infection remains unclear.

When soap and water are not available, the CDC advises using hand sanitizer containing at least 60% alcohol (typically hand sanitizers contain alcohol in the form of ethanol or isopropyl). Sign in to find out how hand sanitizers or disinfectant hand wipes compare to washing hands with soap and water to remove microbes without causing skin dryness and redness.

Be aware that alcohol-based hand sanitizers can cause eye injury and even blindness if they come in direct contact with the eye. This may occur, for example, when dispensers are placed at or above eye level, allowing sanitizer to directly squirt, or reflect off the hands, into the eye, and has been reported in children (Yangzes, JAMA Ophthalmol 2021).

The CDC also notes that benzalkonium chloride, an ingredient in some hand sanitizers, has "less reliable activity against certain bacteria and viruses than either of the alcohols." A review of studies suggests that most alcohol-based hand sanitizers are effective at inactivating coronaviruses in general, although tests of their effects on SARS-CoV-2, the coronavirus that causes COVID-19, were not included (Golin, Am J Infect Control 2020). The researchers also emphasized the importance of using an adequate amount of hand sanitizer, which a study among adults found should be at least ½ teaspoon or more to get complete coverage, but one pump from a dispenser provides only about half of this amount: Two pumps are needed to achieve better coverage. Hand sanitizers used in the study included Purell Advanced Instant Hand Sanitizer and Purell Advanced Instant Hand Sanitizer Foam, each containing 70% ethanol (Kampf, BMC Infect Dis 2013).

Be aware that the FDA has warned consumers not to use a variety of hand sanitizers that have been found to contain methanol. Methanol is toxic and can cause serious illness or death when absorbed through the skin or ingested. See the FDA's page that lists the warnings to-date. Also, fifteen brands of hand sanitizer sold in the U.S. have been found to contain potentially dangerous levels of benzene, a known carcinogen. Sign in to see the list.

Disinfecting wipes

If you use a disinfecting wipe on a surface that may come in contact with food or be placed in the mouth (like a baby bottle), be sure to rinse the surface with water and dry after wiping. A Clorox spokesperson told ConsumerLab that "Clorox Disinfecting Wipes can disinfect plastic packaging that is non-porous. Packaging should not have any holes that would allow the disinfectant to make direct contact with food. The wipes should never be used directly on food and should not be used on paper or cardboard packaging." As some consumers have wondered if the wipes can be used on microwaveable "steam" bags (as for steaming vegetables), it would seem that the wipes can be used on the front and back surfaces but perhaps not at the ends and seams where steam vents are placed.

Clorox wipes have a shelf life of one year from the date of manufacture, and Lysol indicates two years for its wipes.
"

 

[missy]

"

Do any treatments reduce the risk of infection after you've been exposed to someone with COVID-19?​

Written by Meredith Worthington, Ph.D. — Medically reviewed and edited by Tod Cooperman, M.D.
Latest Update
Paxlovid Interaction With Supplements
Last Updated: 05/12/2022

​

Answer:​

There are currently no FDA authorized or approved drugs for post-exposure prevention of COVID-19 due to the Omicron variant. However, there is one monoclonal antibody treatment for pre-exposure prevention of COVID-19 in some people, and there are several drugs authorized to treat COVID-19 if given early to certain patients.

Currently authorized monoclonal antibodies for pre-exposure prevention:​

EVUSHELD (tixagevimab with cilgavimab) is the only product authorized for the pre-exposure prevention of COVID-19 in adults and children 12 and older (weighing at least 88 lbs) who are moderately to severely immune compromised and are unlikely to mount adequate immune response to vaccination, or are not recommended to receive a COVID-19 vaccine due to potential for severe adverse reactions (such as severe allergic reaction).
EVUSHELD is administered once as two separate, consecutive shots consisting of 300 mg of tixagevimab and 300 mg of cilgavimab. At this time, no repeat doses are recommended. However, individuals who received an initial dose consisting of only 150 mg each of tixagevimab and cilgavimab within the past 3 months should receive a second dose of 150 mg each of tixagevimab and cilgavimab, and those who received the lower dose more than 3 months prior should receive a second full dose of EVUSHELD. People who received a COVID-19 vaccine can be administered EVUSHELD at least two weeks after vaccination.
The most common side effects of EVUSHELD are headache, fatigue and cough. Although less common, a higher percentage of people given EVUSHELD reported heart attack and heart failure compared to placebo, although a clear cause-and-effect relationship has not been established. EVUSHELD should be used with caution in people with significant bleeding disorders.
Be aware that the availability of EVUSHELD is very limited in the U.S., but you can search online for the nearest location.

Currently authorized or approved treatments:​

The following drugs have been granted emergency use authorization for the treatment of mild to moderate COVID-19 (but not severe COVID-19) in adults and, unless otherwise noted below, children 12 and older and weighing at least 88 lbs. (40 kg), who are at high risk for progression to severe COVID-19:

• Bebtelovimab: On 2/11/22, the FDA authorized bebtelovimab, a monoclonal antibody, for patients for whom other treatment options are not accessible or clinically appropriate. Laboratory data has shown that this antibody therapy remains active against the Omicron variant and the BA.2 subvariant. It should be started within 7 days of symptom onset. Bebtelovimab is not authorized for use in patients hospitalized with COVID-19, or who require oxygen due to COVID-19, as there is concern it could worsen outcomes in these patients. Laboratory research suggests that bebtelovimab has potent neutralizing activity against all Omicron subvariants, including BA.2 (Liu, medRxiv 2022 — preprint).
• Lagevrio (molnupiravir) is an antiviral drug for the treatment of mild to moderate COVID-19 in adults (but notchildren or adolescents) at high risk for progression to severe disease and for whom other authorized treatments are not accessible or clinically appropriate. It should be started within 5 days of symptom onset.
• Paxlovid (nirmatrelvir plus ritonavir) is the only antiviral drug that is strongly recommended by the World Health Organization for the treatment of non-severe COVID-19 (see the WHO table of treatment recommendations). It should be started within 5 days of symptom onset. In unvaccinated people with COVID who were at high risk for progression but were not hospitalized, giving Paxlovid within 5 days of symptom onset reduced the risk of hospitalization or death by day 28 by 87.8% compared to placebo. Paxlovid was given every 12 hours for 5 days (10 total doses). The most common side effects of treatment were altered taste (dysgeusia), diarrhea, and vomiting (Hammond, N Engl J Med 2022).
  Be aware that Paxlovid should not be used along with drugs or supplements metabolized primarily by the liver enzyme CYP3A4, as Paxlovid may increase plasma concentrations of these drugs. Such agents include colchicine (which is also used in Indian Ayurvedic medicines) and lovastatin (a compound also in red yeast rice supplements). Also, products that are potent activators of CYP3A4 should not be used along with Paxlovid, as these agents can reduce plasma concentrations of Paxlovid and reduce its effectiveness. St. John's wort is an herbal product that can activate CYP3A4, so Paxlovid should not be used with it or immediately after discontinuing it. See the FDA's list of drugs that may interact with Paxlovid. Supplements that inhibit CYP3A4should also not be used with Paxlovid. If you are being started on Paxlovid, tell your healthcare provider if you are taking supplements.

In addition to these authorized treatments, remdesivir (Veklury) is an antiviral drug approved for the treatment of COVID-19 in adults and children 12 and older who are hospitalized with severe COVID-19 or who have mild to moderate COVID-19 but are at high risk for progression to severe disease. It should be initiated as soon as possible after COVID-19 diagnosis.

How to get medical treatment for COVID-19 quickly:​

It is possible to get treated with antiviral medication for COVID-19 quickly through a streamlined the process called "test to treat," which the U.S. government rolled out on March 8, 2022. This program allows people to get tested at certain pharmacies (such as CVS Minute Clinics, HRSA-supported Health Centers or military Medical Treatment Facilities) and, if positive for COVID-19 and eligible for treatment, receive antiviral treatments (molnupiravir or Paxlovid) at the same location, at no cost. People who test positive for COVID-19 through at-home tests or another testing site can also get antiviral treatments prescribed and filled immediately at test to treat sites, but they will need to show their test results. You can find the nearest test to treat location, as well as the antivirals available there, at https://www.covid.gov/ or by calling 1-800-232-0233. Be aware that not all pharmacies listed are part of the test to treat program and may only be able to fill a prescription (such pharmacies will include the statement, "Talk to your doctor or visit a local community health center to get a prescription before going to this location to get medication."). While the medication is provided at no cost, be aware that sites may charge for services (i.e., the cost of providing testing and treatment) if not covered by insurance.

Drugs no longer used:​

The FDA had authorized two monoclonal antibody combination therapies — REGEN-COV by Regeneron Pharmaceuticals, Inc., which is a combination of casirivimab plus imdevimab, and another monoclonal antibody treatment that is a combination of bamlanivimab plus etesevimab — for post-exposure prophylaxis, i.e., to help prevent infection in people who have been exposed to someone with COVID-19. Both of these monoclonal therapies had previously also been granted emergency use authorization for the treatment of existing mild to moderate COVID-19 infection (i.e., not severe or hospitalized cases or cases requiring oxygen therapy).
However, the FDA revised the emergency use authorization for these monoclonal antibody treatments to limit their use for treatment and post-exposure prophylaxis to only cases in which the COVID-19 patient is likely to have been infected by or exposed to susceptible variants. Since Omicron is now predicted to account for more than 99% of COVID-19 cases in the U.S. and is unlikely to be a susceptible variant, these monoclonal antibody therapies are not authorized for use in any U.S. state, territory or jurisdiction as of 1/24/22. There are no other drugs authorized or approved for post-exposure prevention of Omicron.
Similarly, the monoclonal antibody treatment sotrovimab was previously authorized for the treatment of mild to moderate COVID-19 in adults and children 12 and older who were at high risk for progression to severe disease. However, this was revised by the FDA in February, 2022 to prohibit its use in regions in which COVID-19 infections are likely caused by a variant that is non-susceptible to sotrovimab, such as Omicron BA.2. On April 5, 2022, sotrovimab became no longer authorized for use in any region in the U.S. since the prevalence of the BA.2 variant was estimated to be greater than 50% in all regions (ASPR Important Update, 4-5-22).

"

 

[missy]

"

I had Covid. When can I get back to life?​

In this week's edition of the Covid Q&A, we look at when you can get back to life after having the virus. In hopes of making this very confusing time just a little less so, each week Bloomberg Prognosis picks one reader question and puts it to experts in the field. This week’s question comes to us from Emma in Brooklyn, New York. She asks: I just had Covid. When is it safe to have a friend stay over, or have the housecleaner come or go out to the dry cleaner? This is one of those questions that seems like it should have a straightforward answer, and yet, as both science and our attitudes toward the pandemic have shifted, the answer has changed, too. “For most people, it will take about 10 days,” says Jessica Justman, an epidemiologist at Columbia University’s medical school. Justman says that on the first five days of your illness, it‘s important to fully isolate. “Count your first day of symptoms or the day you tested positive as Day 0, whichever results in a longer period of isolation,” she says. “During isolation, you need to stay home and avoid being near others. If you must be around others at home, wear a well-fitting mask. You should not go anywhere that is a public indoor setting — including the dry cleaners or the grocery store. If you go outdoors, keep a mask on and do not go to crowded outdoor settings.” During isolation, if you must be around others at home, wear a well-fitting mask. Photographer: Angus Mordant/Bloomberg After Day 5 though, says Justman, it’s OK to ease up on the quarantine, while still being careful around others. “For Days 6 to 10, if your symptoms are clearly better and you haven’t had a fever for 24 hours (without using acetaminophen or other medications to reduce fever), you can go out while taking precautions,” she says. Those precautions should include continuing to wear a mask around others in your home and wearing one any time you’re in public. Justman says you shouldn’t eat at a restaurant or go over to a friend’s house during this period. And, as nice as it would be to have someone else clean up all that quarantine mess, it’s better to wait on the cleaner, too. “If you can wait till Day 10 to have the housecleaner come, that would be better,” she says. “If not, keep a mask on and have the housecleaner keep a mask on the whole time.” If you’ve had a severe case of the virus or have a weakened immune system, Justman says you should completely isolate for at least 10 days and then consult with your doctor before ending isolation. Otherwise, after Day 10, if your symptoms are resolving and you are fever-free, it’s safe to finally get back to business as usual. "

 

[Gloria27]

Isolating in the same house from loved ones that have covid instead of caring from them, wow, reminds me of that woman who put her kid in the trunk of her car to "prevent exposure", humanity's new low...

 

[missy]

"

CDC Says COVID Hospitalizations to Rise in Most States​

Carolyn Crist

As U.S. COVID-19 cases reach the highest levels since mid-February, hospital admissions and deaths are projected to increase during the next four weeks, according to a new update from the CDC.
The forecast, which includes 32 different models across the country, predicts that nearly every U.S. state and territory will see increases in new COVID-19 hospitalizations in the next two weeks.
In addition, between 2,000-5,300 deaths will occur by June 11, the models show. California, Georgia, Florida and New York are projected to have the largest death tolls.

The projected increases line up with the recent growth in cases and hospitalizations. More than 100,000 new cases are being reported each day, according to the data tracker from The New York Times, marking a 57% increase in the past two weeks.

In the last six weeks, new cases have quadrupled nationally, according to ABC News. In the past week alone, the U.S. has reported about 660,000 new cases.
Nearly 25,000 patients are hospitalized with COVID-19 nationwide, according to the latest data from the U.S. Department of Health and Human Services, marking a 29% increase in the past two weeks and the highest total since mid-March.
About 3,000 coronavirus-positive patients are entering the hospital each day, which has increased 19% in the last week, ABC News reported. Admission levels are now rising in every region of the country, and virus-related emergency room visits are at the highest point since February. Pediatric hospital admissions have also increased by 70% during the last month.

About 300 COVID-19 deaths are being recorded each day, The New York Times reported. Deaths haven't yet begun to increase but are expected to do so in the next two weeks, the CDC forecast indicates.
The Northeast is considered the current COVID-19 hotspot, ABC News reported, with some of the highest case rates per capita being reported in New York, New Jersey, Massachusetts, Rhode Island and Washington, D.C. Hawaii, Puerto Rico and the Virgin Islands have also reported high case rates.
The areas with high COVID-19 community levels will likely see a "high potential for healthcare system strain" and a "high level of severe disease" in coming weeks, the CDC said.

Sources​

COVID-19 Forecast Hub: “COVID-19 US Weekly Forecast Summary, May 17, 2022.”

The New York Times: “Coronavirus in the U.S.: Latest Map and Case Count, updated May 19, 2022.”

ABC News: “Nearly every state expected to see increase in COVID-19 hospitalizations, forecast shows.”

U.S. Department of Health and Human Services: "Hospital Utilization."
"

Q and A

"
I keep reading that the new coronavirus subvariants are "more transmissible" than their predecessors. But what does "more transmissible" actually mean?

The basic concept of infectivity is pretty straightforward, according to John Brownstein, an epidemiologist and chief innovation officer at Boston Children’s Hospital: How many additional cases does a single case generate?

The reason certain variants and subvariants take over is because they have an evolutionary advantage and outcompete other variants by infecting more people. Understanding the mechanisms is more complicated, Brownstein said, and include examining inherent properties of the virus, such as how it infects cells and evades immunity. Scientists are figuring that out with omicron and its subvariants.

What does all this mean in real life? To avoid infection, you should apply “additional layers of protection,” Brownstein said, including both non-pharmaceutical measures such as mask-wearing and social distancing and our chief pharmaceutical weapon –- staying up to date on vaccines.

“There’s nothing particularly different,” Brownstein said. “We know that works.”
"

Is a Longer Paxlovid Course Needed to Combat Re-infection?

"

US to Study Whether Longer Paxlovid Course Needed to Combat Reinfections​

By Michael Erman


(Reuters) - The U.S. National Institutes of Health is in talks with Pfizer Inc about studying whether a longer course of the drugmaker's COVID-19 antiviral treatment Paxlovid is needed to prevent infection recurrence, top U.S. infectious diseases expert Dr. Anthony Fauci said on Wednesday.
"We're going to be planning what studies we're going to be doing relatively soon, within the next few days" in order to determine whether or not a longer course is needed, Fauci said during a White House COVID-19 briefing.
Rising COVID-19 cases in the United States are driving up use of therapeutics, with more than 660,000 courses of Paxlovid pills administered in the country so far.
Some patients have reported that COVID symptoms recurred after completing the five-day course of treatment and experiencing improvement, but exactly how many have experienced such a rebound is unclear.

In Pfizer's clinical trial, around 2% of recipients who received the two-drug treatment saw an increase in viral load after completing the standard course, compared with around 1.5% of placebo recipients.

White House COVID-19 response coordinator Dr. Ashish Jha said that data was compiled when Delta was the dominant variant of the coronavirus, and it is unclear whether recurrence is more common with Omicron now predominant.
Jha said that such reinfections do not seem to hamper Paxlovid's ability to reduce hospitalizations and deaths from COVID-19.
Pfizer has suggested that a second five-day course of Paxlovid could treat a resurgent infection. The U.S. Food and Drug Administration said there is currently no evidence to support taking a second five-day course, or a 10-day course, of the pills.
"

 

[missy]

"​

Long Covid-19: 'I'm physically and mentally not able to do anything'​

Published3 hours ago


One Christmas, Michelle Kibble was given a mug with 'chaos coordinator' printed on the side because she was so busy juggling her full-time job in a pharmacy with being the main carer for her bed-bound father and running a small business with her husband of 25 years, Terry.
But Michelle and Terry's lives changed forever when Michelle, 47, from Swindon, almost died after contracting Covid-19. It left her disabled, she lost her job, and became fearful of leaving the house in case she caught the virus again.
In her own words, Michelle tells the BBC how the trauma has affected her family and how she is managing to cope.
I had a really bad headache for about three or four days in November 2020. It got to the stage where the pain was so severe I used to bang my head against the wall.
My husband could hear me and he called 111. The paramedics came and apparently the oxygen levels in my body had dropped considerably so they took me to hospital.

They did a Covid test and we were both positive. My husband did get ill but with mild symptoms.

Ms Kibble was given a 12% chance of survival after being put into a coma and on a ventilator
I ended up in intensive care and just went downhill. I was put into a coma and on life support.
They phoned my husband regularly but one day they called him and said, 'look you need to make everybody aware and prepare for the worst as she's not going to make it to the morning'.
The doctors said I only had about a 12% chance of survival and they didn't know if I did wake up whether or not I would be brain dead because apparently I had lack of oxygen go to my brain.
I don't remember any of it but I can't even begin to imagine what my husband went through.
I was discharged from hospital in January 2021. When I first came out, Terry would break down. He was just so completely devastated.
When you think you're going to lose that person, you will never see them again, it just changes your whole life.

Just as we came home and were trying to get our life on track, they confirmed I had lung disease and it's never going to get any better.
I have had MRI scans and tests and have been referred to the memory clinic. I had memory problems before Covid but now they are severe.

Terry was unable to visit his wife Michelle for almost two months while she was in hospital
I am physically and mentally not able to do anything. I don't go out. I can barely walk far without getting really out of breath.
My husband sometimes has to even carry me upstairs to bed if I can't make it up the stairs by myself.
Being so motivated and so full-on and physical and then all of a sudden you can't do things any more is hard.
I think there's a lot of people out there that don't understand. If I say I'm breathless or I get tired easily they'll just say, 'oh, pull yourself together' but it's so much more than that. It's life changing.

I used to work full-time as a pharmacy dispenser for 12 years, Monday to Friday and Saturdays, but I have now lost my job. I also looked after my dad as his full-time carer.
Financially it's been really hard. We've had to cut our cloth accordingly. I do get a small amount from disability allowance but it's only the basic but then every little bit helps.
The main thing I miss the most is independence. I think when you're not earning you feel maybe 'I shouldn't buy that because I've not earned the money'. I do feel guilty.

Ms Kibble's lungs were mainly healthy before she had Covid-19 with some white scarring

Her lungs became heavily scarred after she developed pneumonia and she now has lung disease
I very rarely have contact with people. I haven't seen my dad since I caught Covid. I'm not sure where I caught the virus from. It may have been at my dad's, possibly from one of his carers, and that's why I'm cautious of going there.
So it has been hard not to be able to see him but I have to protect myself. I've always put myself last but I have to put myself first for a change.
I know it's really silly but I'm really cautious about everything I do.
Because it's had such a major impact on our life and the trauma that it caused, I just don't want to take that risk any more. I want to be safe in my home. I don't go out socialising. I've not been in touch with my friends.
With the lung disease, I have to have lung function tests and I am due to have breathing tests. I will be constantly on medication and I also have a thyroid problem since having Covid.
But apart from that it's just pain management really.
I'm hoping to get in the right frame of mind to not be so worried when I do go out. There's still loads of things we want to do. We're not old yet.
I think moving forward, if they can get my breathing under control and the medication does its thing then I can try to get out a bit more.
I want to live a life as normal as I can with my husband and my family. To keep going is the only thing I can do.

"

 

[missy]

Covid-19 linked to impaired heart function, study finds​

Published4 hours ago
"
Covid-19 is associated with impaired function of the right side of the heart, new research on intensive care patients has found.
Led by experts from NHS Golden Jubilee, the Covid-RV study was carried out in 10 intensive care units in Scotland.
It assessed the impact the virus had on 121 critically ill patients who required treatment on ventilators.
About one in three patients showed abnormalities in the side of the heart that pumps blood to the lungs.
Nearly half (47%) of ventilated patients in the study died because of Covid-19, a figure comparable to national and international death rates.
The research, conducted at the height of the pandemic from September 2020 to March 2021 before the full impact of the vaccine programme kicked in, sought to help improve future care and outcomes for those most at risk from the virus.

Dr Philip McCall, lead author of the study and consultant in cardiothoracic anaesthesia and intensive care at NHS Golden Jubilee, said a combination of factors "create the perfect storm for Covid-19 to damage the right side of your heart", which can ultimately cause death.



"If you're pumping blood to the lungs and the lungs become very sick, you have an additional problem because the lungs are not willing to receive blood," he explained.
"This is a very difficult condition to spot, unless you are specifically looking for it. That is why the results of this study are so important.
"We now know that Covid-19 is a problem associated with not just ventilation, but can affect the heart."

'Invaluable knowledge'​

Traditionally, such studies would take at least a year just to plan, but because of the pandemic the research was carried out in an accelerated timeframe and completed in a little under seven months.
Experts at the Golden Jubilee National Hospital in Clydebank said the findings could play a vital role in not only saving the lives of Covid-19 patients, but for the care of potentially fatal heart and lung issues generally.

Nearly half of patients n the study who required ventilation died because of Covid-19
Dr Ben Shelley, chief investigator of the study and an intensive care consultant at the hospital, said the study - published in the journal Anaesthesia - revealed there was "no doubt Covid-19 affects the heart" and had a major impact on outcomes for the patient.
He said new care plans and treatments could be put in place to help combat the effects, such as ultrasound scans being used differently to focus on areas at risk.
"If we are able to see these warning signs early enough, clinicians can explore the causes of any complications and start new treatments as soon as possible, potentially improving outcomes for the sickest patients with Covid-19," he added.
"This kind of knowledge is invaluable, not only in combatting any future waves of Covid-19, but in planning for future pandemics to allow people to be treated more effectively."

Heart inflammation​

Meanwhile, a different study led by the University of Glasgow found one in eight people admitted to hospital with Covid-19 between May 2020 and March 2021 were later diagnosed with myocarditis, or heart inflammation.
The research, carried out in collaboration with NHS Greater Glasgow and Clyde and published in Nature Medicine, followed 159 patients for one year after they were hospitalised with the virus.

Until now it had been thought that previous underlying health conditions may have been linked to the severity of post-Covid long-term effects.
But Professor Colin Berry, a cardiology professor at the University of Glasgow, said the study suggested the severity of the infection itself was most closely correlated to the nature of a patient's long Covid symptoms, rather than pre-existing health problems.
"We found that previously healthy patients, without any underlying health conditions, were suffering with severe health outcomes, including myocarditis, post hospitalisation," he said.


"





"
Monkeypox; Tools to keep COVID-19 Endemic now Here
HI all, There is a monkeypox outbreak (about 100 cases as of May 20, 2022) worldwide mainly in UK, Canada with some cases across Europe and 2 cases in the US as of this writing. Monkeypox is easy to contain as symptoms as very distinguishable (unlike COVID which can look like a lot of different respiratory pathogens) with a specific rash and lymphadenopathy. In terms of COVID, our deaths continue to decline here in teh US and many articles now pointing out that our COVID hospitalization data in the US is not reliable as no state except Massachusetts breaks out "with COVID" (COVID in nose) versus "for COVID" hospitalizations. MA does a great job and finds about 70% of COVID hospitalizations incidental and 30% for COVID so death rate from COVID (continues to decrease) may be most reliable marker of severe disease at this point- would be consistent with our high levels of immunity with the CDC seroprevalence study showing 60% nucleocapsid antibodies in adults and 75% in children 0-18 (April 26, 2022) and a COVID vaccination rate of 82.5% 1st dose in those >5 years old. Hybrid immunity seems to be strongest defense which is why places like Bay Area with less natural immunity from lockdowns having higher cases than places with more hybrid immunity right now with BA.2.12.1 Tools to control COVID are vaccines, Evusheld (monoclonal antibody) for severely immunocompromised and Paxlovid for those at risk of a severe breakthrough once infected. Thanks,
"

 

[missy]

Opinion | My Patient Didn’t Die From Covid. He Died Because of It.

These pandemic deaths are still uncounted.

www.nytimes.com

"​

My Patient Didn’t Die From Covid. He Died Because of It.​

May 21, 2022

By Sunita Puri
Dr. Puri is the author of “That Good Night: Life and Medicine in the Eleventh Hour.”
Lucas Callender told me that after cheating death, he had become kinder. When he was a teenager, an aggressive tumor had gnawed through part of his thigh muscle. After surgery and chemotherapy, his cancer was undetectable. He became the type of guy who would dress up as a princess for his niece’s birthday, or go to five different stores to find his dog’s favorite chew toy.
In January 2020, he celebrated ten years cancer-free. But a few months into the pandemic, his back began to ache. He figured he’d slept funny or overdone it when moving furniture for his mother. But his back soon throbbed with such intensity that he started biting his pillow whenever he sat up in bed. Normally, he’d have made an appointment with his doctor or gone to the emergency room. Instead, he watched doctors on the news warn people to stay away from hospitals unless they couldn’t breathe. Afraid of catching the coronavirus and joining the escalating number of the dead, he stayed home.
But in June 2020, when he began to feel as though putting any weight on his right leg would shatter it, his mother drove him to the emergency room. His cancer had returned and spread throughout his pelvis and spine. This time, it was incurable.
As a palliative care physician, I was called to help manage Lucas’s pain. We met in the I.C.U., where he needed such high doses of pain medication that I had to monitor his heart rate and breathing closely. He died a year and a half later, after a series of harsh, unsuccessful chemotherapies and risky surgeries. His mother, inconsolable, told me she wished her son’s cancer had returned in 2019, when he would never have hesitated to call his doctor, instead of 2020, the first year of the Covid pandemic.

One million Americans have died of Covid-19. And while many researchers believe that this is an underestimate, intense effort has been made to catalog each death as meticulously as possible.
But my patient didn’t die of Covid-19. Instead, he almost certainly died because of Covid-19.
It is unclear exactly how many people like Lucas died as a consequence of the pandemic’s disruption of health care. Their stories drew too little public attention, and their deaths, in the shadows, will probably remain uncounted forever. The pandemic limited access to mental health services and routine care, leaving their depression and hypertension untreated. We may never know how many people with chest pain died away from the hospital because the news that night was filled with images of Covid patients gasping for air in crowded E.R. hallways. But health care systems and government officials still must make every effort to understand the reasons these people died shadow deaths if there is to be any hope of preparing a humane and equitable response for the next public health emergency.



Between March 2020 and January 2021, over 500,000 more people in America died than had in the same period a year earlier, an estimated 28 percent of them from causes other than Covid, such as heart attacks, strokes and Alzheimer’s. Visits to clinics providing primary and specialty care plummeted, often in concert with stay-at-home orders. Patients of color suffered a disproportionately high number of excess deaths because of longstanding barriers to care made worse by the pandemic.
In the eyes of many, the pandemic transformed places of care into places of contagion. More than 40 percent of adults surveyed by the Centers for Disease Control and Prevention decided in the early months of the pandemic, as my patient had, to forgo medical care because they feared exposure to the virus; 12 percent even avoided emergency care.
Some patients suffered evolving symptoms until a crisis arose. Many felt forced to self-triage. My patients’ decision making suddenly required intense cognitive gymnastics: I have to get a CT scan before chemo, but what if I come home with Covid and infect my family? If I go the E.R. with stomach pain, and they’re busy, do I wait it out or come home to avoid getting infected?
While fumbling through the dark landscape of tragedy, my colleagues and I have often mourned the stories of patients who sought out medical care despite their fears about contracting Covid, only to become casualties of an overburdened system. Early in the pandemic, a colleague told me about an elderly patient with heart disease who died in the emergency room while waiting nearly a day to be admitted to a hospital filled with Covid patients. During the 2020 winter surge in Los Angeles, another patient developed a terrible headache at home, and by the time paramedics arrived an hour later, blood had flooded her brain. She never regained consciousness.
Around the same time, a woman with cirrhosis began to drink more heavily and couldn’t get a timely appointment with her usual physician, who’d been deployed to treat Covid patients in the hospital. Shortly after she went to an urgent care center, she died from liver failure.
The families of these people suffered the singular ache of wondering whether they had pushed their loved ones hard enough to go to the hospital or advocated sufficiently for them to get the care they needed. Their doctors often wondered the same.
I’ve thought about whether listening to patient stories earlier in the pandemic might have improved health care systems’ responses to their needs during these tumultuous years. In April 2020, leaders at Adventist Health Lodi Memorial, a community hospital in central California, noticed that visits to the emergency room dropped by around 50 percent shortly after California issued its first stay-at-home order. Paramedics reported a record number of cardiac arrests outside the hospital, and patients with strokes almost uniformly waited to seek help until the severity of their symptoms worsened.
A team of researchers mainly from the University of California, San Francisco, interviewed patients and physicians in Lodi about their health care experiences during the early months of the pandemic and reported, “the overarching theme from these interviews was fear.” To feel safe, patients said they needed to understand the hospital’s efforts to minimize transmission of the virus as well as clear guidance about when to go to the emergency room and reassurance that they would receive care.
The hospital responded swiftly. Patients with respiratory symptoms that could signal Covid were evaluated in one part of the emergency room, a safe distance away from others. Patients received emails about the measures taken to keep the hospital clean, the prevalence of Covid cases in the community and what symptoms should prompt an immediate visit to the emergency room. People soon began to return to the emergency room, and lives were potentially saved.
The health care system should emulate Lodi Memorial’s approach and pursue the stories of those who died shadow deaths in order to prevent such deaths from happening amid the next crisis or surge. Researchers and policymakers must investigate and learn from the experiences of people like my patient and the patients in Lodi to understand how to minimize obstacles to getting care even amid the tumult of a pandemic — particularly emergency care for people suffering heart attacks and strokes.

There is, of course, no way to plan for every permutation of disaster. But acknowledging fallibility cannot subvert the urgency of translating these stories into change, which can begin at the local level. Individual hospitals should calculate their system’s excess deaths, compare their data with that of other hospitals and survey patients and families to understand what factors influenced their medical decision making. Local research should inform state and national public health messaging, balancing a need for caution with guidance about when to seek emergency care, and where. And, as always, access to primary and preventative care must increase in order to minimize deaths from chronic illnesses.
Our health care system must act now, before the next crisis strikes. There may be no list of people who died in the shadows of the pandemic, but decreasing their future numbers is a powerful way to memorialize them.
As Lucas grew sicker, I found myself rewriting his story, swapping the reality unfolding before me for an ending I thought he deserved. I imagined it was 2019 and he was dancing with friends at a holiday party when he felt a bolt of pain in his back. He toughed it out for a few days, then went to his doctor. On his CT, tumor glowed in just one place; after surgery, it vanished, and he was healed once again. A few months later, he’d ask out the woman he met at the party. He’d roughhouse with his dogs, carry his niece on his shoulders so she could see the world from his point of view.
In my version of his life, he would never be my patient.

"

Sunita Puri (@SunitaPuriMD) is a palliative medicine physician and the author of “That Good Night: Life and Medicine in the Eleventh Hour.”

 

[missy]

From on of our physicians newsletter FYI


“

Covid Vaccines


There are a couple of changes to vaccine recommendations.
1. People over 50 and people over 12 who are immunocompromised SHOULD get a booster. It was previously stated that this group could get the booster but the recommendation has been strengthened to state that this group should get the booster. This decision is likely driven by the new surge. You could choose either Moderna or Pfizer for the booster dose, regardless of what you took for your primary series.
2. People 5-11 should get a Pfizer booster at least 5 months after the primary series.
3. People 5-11 who are immunocompromised should get a Pfizer booster at least 3 months after the primary series.
4. Another new recommendation is that people who had a Covid infection should delay getting a vaccine or a booster shot for 3 months after testing positive.

Paxlovid
A lot of people are asking me about the anti-viral drug Paxlovid. NYC now has eligibility criteria for prescribing Paxlovid. In order to qualify for Paxlovid, all of criteria 1-6 must be present.
The Food and Drug Administration (FDA) has issued an emergency use authorization (EUA) for Paxlovid for the treatment of COVID-19 in individuals who meet all the following criteria:

1. Test positive for COVID-19 on a nucleic acid amplification (NAA) or antigen test, including an FDA-authorized home-test kit
2. Are age 12 or older and weigh at least 88 pounds (40 kilograms)
3. Are age 65 or older or have a medical condition or other factor that increases their risk for severe COVID-19. More information on underlying medical conditions can be found by visiting

https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html

1. Have mild to moderate COVID-19 symptoms
2. Can start treatment within five days of symptom onset
3. Are not hospitalized due to COVID-19 when treatment is initiated

Paxlovid reduces the risk of severe disease and death from Covid. People who do not meet the above criteria are already at a low risk of severe disease and death at a baseline – especially if they are vaccinated. There is no evidence that Paxlovid changes the risk of Long Covid.
Some people who take Paxlovid report a reduction in symptoms during the course of treatment. Among those people, some have reported a recurrence of symptoms and recurrence of positive rapid testing after completing the course of Paxlovid. This is concerning, considering the recurrence often occurs after Day 10 of isolation. The impact of recurrence is being investigated, but there are no official guidelines about it yet.

Just posted new official guidelines if one relapses after using Paxlovid.

Recent case reports document that some patients with normal immune response who have completed a 5-day course of Paxlovid for laboratory-confirmed infection and have recovered can experience recurrent illness 2 to 8 days later, including patients who have been vaccinated and/or boosted (were up to date with COVID-19 vaccination) (2-4). These cases of COVID-19 rebound had negative test results after Paxlovid treatment and had subsequent positive viral antigen and/or reverse transcriptase polymerase chain reaction (RT-PCR) testing.

Advise people with COVID-19 rebound to follow CDC’s guidance on isolation and take
precautions to prevent further transmission. Patients should re-isolate for at least 5 days. Per
CDC guidance, they can end their re-isolation period after 5 full days if fever has resolved for 24
hours (without the use of fever-reducing medication) and symptoms are improving. The patient
should wear a mask for a total of 10 days after rebound symptoms started.


Isolation Instructions for those with Covid infection:
This has changed slightly. I put the new info in italics.
First things first: Do your own contact tracing starting 2 days before symptoms (or positive test if you are asymptomatic).
If you had COVID-19 and had symptoms, isolate for at least 5 days. To calculate your 5-day isolation period, day 0 is your first day of symptoms. Day 1 is the first full day after your symptoms developed. You can leave isolation after 5 full days.

• You can end isolation after 5 full days if you are fever-free for 24 hours without the use of fever-reducing medication and your other symptoms have improved (Loss of taste and smell may persist for weeks or months after recovery and need not delay the end of isolation).
• You should continue to wear a well-fitting mask around others at home and in public for 5 additional days (day 6 through day 10) after the end of your 5-day isolation period. If you are unable to wear a mask when around others, you should continue to isolate for a full 10 days. Avoid people who have weakened immune systems or are more likely to get very sick from COVID-19, and nursing homes and other high-risk settings, until after at least 10 days.
• If you continue to have fever or your other symptoms have not improved after 5 days of isolation, you should wait to end your isolation until you are fever-free for 24 hours without the use of fever-reducing medication and your other symptoms have improved. Continue to wear a well-fitting mask through day 10. Contact your healthcare provider if you have questions.
• See additional information about travel.
• Do not go to places where you are unable to wear a mask, such as restaurants and some gyms, and avoid eating around others at home and at work until a full 10 days after your first day of symptoms.

If an individual has access to a test and wants to test, the best approach is to use an antigen test1 towards the end of the 5-day isolation period. Collect the test sample only if you are fever-free for 24 hours without the use of fever-reducing medication and your other symptoms have improved (loss of taste and smell may persist for weeks or months after recovery and need not delay the end of isolation). If your test result is positive, you should continue to isolate until day 10. If your test result is negative, you can end isolation, but continue to wear a well-fitting mask around others at home and in public until day 10. Follow additional recommendations for masking and avoiding travel as described above.

Quarantine for vaccinated people who were exposed to Covid:
You do not need to stay home unless you develop symptoms.
Get tested
Even if you don’t develop symptoms, get tested at least 5 days after you last had close contact with someone with COVID-19.

Watch for symptoms until 10 days after you last had close contact with someone with COVID-19.
If you develop symptoms,isolate immediately and get tested. Continue to stay home until you know the results. Wear a well-fitting mask around others.
Take precautions until day 10.
Wear a well-fitting mask for 10 full days any time you are around others inside your home or in public. Do not go to places where you are unable to wear a well-fitting mask.
Avoid being around people who are more likely to get very sick from COVID-19.
.
“