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By Mary Carpenter
REINFECTION RISKS and Long Covid have become topics of unreliable Covid public health messaging in the U.S. — mostly because the virus is relatively new and continually evolving, which has confounded large, long-term research efforts. The emphasis on hospitalization and death as the greatest risk of Covid infection appears increasingly misplaced—along with the contention that lasting Covid symptoms afflict mostly those who had not received vaccinations, or who had severe infections or pre-existing medical conditions.
“We failed in our health messaging,” writes Carnegie Mellon University ethics and philosopher professor Danielle Wenner and colleague. Lack of publicity about the high risk of Long Covid symptoms “deprives the public of the knowledge necessary to…make informed decisions about risk-taking and understand what is happening to them if they feel sick for an extended period.”
And while reinfection may be a buzzword for early-summer 2022 Covid, getting sick continues to surprise those who fall ill, despite having had vaccinations and previous infections. South African epidemiologist Juliet Pulliam told the New York Times,“Omicron and its many descendants seem to have evolved to partially dodge immunity [leaving] everyone – even those who have been vaccinated multiple times – vulnerable to multiple infections.”
“A striking jump in transmissibility” is how Scripps molecular medicine professor Eric Topol characterized Omicron—beginning with the dominance of the Omicron BA.1 variant that had “at least a threefold increase in reproductive number beyond Delta.” Next came a quick transition to a BA.2 wave with at least another jump of about 30% transmissibility. Now the U.S. is heading to a “dominant subvariant known as BA.1.12.1, which is another 25% more transmissible than BA.2 and already accounting for about 50% of cases.”
The best Covid news comes from Japan, which has long emphasized avoiding sanmitsu, or the 3Cs: closed environments, crowded conditions and close-contact settings. Through six waves of Covid-19 and despite having the world’s oldest population, the number of cases and deaths per capita in Japan has been consistently lower than in the U.S., beginning even before masks became common and vaccines became available—though Japanese vaccination rates are now high.
The CDC defines Long Covid as “the occurrence of new, returning or ongoing health problems four or more weeks after an initial infection with SARS-CoV-2.” Symptoms vary from person to person and may include breathing problems, extreme fatigue, cognitive and memory issues — along with loss of smell or taste, heart palpitations, sleep difficulties, mood changes and tremors. For the WHO definition, symptoms must last at least two months.
[Long Covid is] “generating a pandemic of people who were not hospitalized but who ended up with this increased disability,” infectious disease epidemiologist at Penn State Paddy Ssentongo told the New York Times. A recent analysis of 78,252 privately insured patients in the U.S. found that 76% of Long Covid patients had not required hospitalization for their initial infection; and nearly a third of patients had no pre-existing health conditions in their medical record.”
And “there was no difference between the vaccinated and unvaccinated” in studies that included 33,940 people by the Department of Veterans Affairs, for longer term risks of neurological issues, gastrointestinal symptoms, kidney failure and other conditions—although being vaccinated seemed to reduce the risk of blood clotting and lung complications clotting disorders, according to the Washington Post.
But inconsistencies have plagued research and undermined conclusions, writes Elizabeth Yuko in Rolling Stone: “Studies are measuring Long Covid at different intervals and capturing different populations within Long Covid.” In addition, most published results to date come from studies on Delta and earlier variants of the coronavirus, rather than on the currently dominant Omicron. “Long Covid has yet to be adequately defined,” according to Jaime Selzer, director of an advocacy organization focused on myalgic encephalomyelitis/chronic fatigue syndrome—which estimates that 10 to 12 % of those with Covid infections will develop the condition. And disagreement persists on the name for Long Covid, with the new diagnostic code U09.9 for “Post covid-19 condition, unspecified”— recently added by the International Classification of Diseases but not yet widely adopted —after endless earlier iterations, such “post-acute sequelae of Sars-CoV-2 (PASC).”
In addition to Long Covid, acute infection appears to increase risk of cardiovascular problems, such as stroke and heart failure. And recent studies have found post-infection cases of hepatitis in children and of diabetes in adults, although researchers are still sifting through the variables such as pre-existing health issues.
Increased availability of the antiviral medication Paxlovid initially relieved fears of Long Covid, which appears more likely when infections are severe or long-lasting. According to Yale immunologist Akiko Iwasaki, “The quicker one can eliminate the virus, the less likelihood of developing persistent virus or autoimmunity, which may drive Long Covid.”
But in recent cases of infections halted by Paxlovid, Covid symptoms have reappeared within a few days, with tests positive once again. While attributed to a “rebound” effect of the drug, these experiences have raised fears of viral resistance —“the hobgoblin of antiviral medicine,” according to STAT, which has occurred with “nearly every new virus-killing infusion or pill in history… either immediately or eventually.”
“We’re not going to normal 2019,” University of Pennsylvania Provost of Global Initiatives Ezekiel Emanuel told Stat. For the future, the most optimistic scenario has deaths from Covid reduced to between 15,000 and 30,000 per year— but a more virulent virus and waning immunity could bring that toll to nearly ten times as high. On the other hand, improvements in indoor air quality could help reduce total numbers of deaths from influenza and other flu-like illnesses as well as Covid.
With H.I.V., the CDC eventually shifted its prevention strategy away from broad-scale public awareness campaigns to focused H.I.V. testing in populations at highest risk, writes epidemiologist and infectious disease professor Jay Varma at Cornell Weill Medical Center in a New York Times article titled “The Answer to Covid Fatigue is Creativity, not Surrender.” As H.I.V. fears began to ebb, the CDC embraced what’s known as structural approaches to prevention —making “testing, treatment and condoms so widely accessible and acceptable that individuals would have to actively choose not to use them.”
For now, though, the Japanese way may be the best path forward, following the 3C’s—plus masking. Even as much of the population relaxes precautions, the new mantra of “one-way masking” will provide additional protection for people worried about risks of Covid, and especially of persistent symptoms—whatever the official label—that last long after the infection has subsided.
—Mary Carpenter continues to update us on the latest news from the Covid-19 front.