mortality

The Long Haul, Part 4: The Cost of Long COVID In Terms Of Individual Health And Quality Of Life

Surviving COVID-19 is one thing, recovering is another.

My frustration with those who would minimize the impact of COVID-19 is reaching an apex. I constantly have to deal with their baseless rationalizations that “it is just a cold,” or “it only kills 0.01% of people” (actually the number is 2% around the world), etc. And I constantly reply to these iconoclasts that COVID has become, by far, the leading killer in the US. I also explain over and over that treating simple mortality percentage as the only relevant statistic to consider is falderal. For example, the Spanish flu also killed “only” 2% of those infected, but in just 24 weeks, that virus killed more people around the world than were killed in WWI AND WWII together! The percent figure is meaningless without considering the percent of what. Why do they continue to ignore the devisor and, hence, the total number of deaths?

A small percentage of a very large number is, in fact, another large number.

Those who wish to downplay the significance of the pandemic only focus on this mortality percent, but mortality is NEVER the whole story for any pandemic. A serious person will also consider the morbidity caused by the disease. In fact, the major CDC publication on health in the US is called the Morbidity and Mortality Weekly Report. Notice that it considers both morbidity and mortality, and further notice that morbidity is listed first in the title. I have made three prior posts in this series on Long COVID, about the significant lasting morbidity of COVID-19. You can see these posts here, here, and here. In those posts, I shared data showing that some ~10-30% of COVID survivors suffer serious health problems that last months.

In those posts, I mentioned the cases of a young, healthy MD, and of a young, healthy journalist, both of whom struggled with long COVID, and how it affected their careers and cost them thousands of dollars in out-of-pocket expenses for the dozens of tests and doctors they needed. In an article in Maclean’s magazine, a reporter interviewed many Canadian long COVID patients and heard how their lives have been turned upside down. They reported that they are unable to live like they used to and care for their families, do anything mildly strenuous, or even cook their meals. They spend long stretches of time in bed. Many of those interviewed had not returned to work several weeks after recovering from the acute disease.

Anecdotes like these have been repeated millions of times around a world that, according to the Johns Hopkins University COVID tracker, has seen more than 330 million cases of COVID (and this is a significant undercount since many countries do not record these data well). Research has corroborated these anecdotes.

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Common long-term symptoms include debilitating fatigue; respiratory problems; and “brain fog.”  Other common symptoms include compromised function of the heart, and kidneys, which sometimes require transplantation. Wide-spread clotting problems can cause significant illness and even limb amputation. There also are frequent neurological and neuropsychiatric symptoms as highlighted in Part 3 of this series. Surprising manifestations continue to emerge, such as new-onset diabetes.

Lung scarring often occurs in patients who experienced COVID-caused acute respiratory distress syndrome (ARDS), a common problem seen in acute COVID patients who required ICU care. ARDS is a serious respiratory problem that can be caused by different respiratory viruses and other things. About a third of patients with ARDS arising from any cause were unemployed 5-years later because of their lung damage. It is fully expected that patients with COVID-related ARDS will be found to fare similarly.

There also is the dysfunctional immune response common in many moderate to severe COVID cases that can cause long-term multi-organ damage, particularly in the liver and kidneys. It can also disrupt coagulation control of the blood, sometimes leading to amputations, mostly in patients in their 30s and 40s. It was reported that amputations due to vascular problems have doubled since the CoV-2 virus arrived. Compromised coagulation control in COVID patients can also precipitate adverse cardiovascular events such as heart failure, or hemiplegia due to strokes. Data from the COVID Infection Survey on long-COVID suggest that the risk of major adverse cardiovascular events and long-term illness is about ten times higher in COVID patients (even after mild COVID) compared to non-COVID matched controls. A Dutch study found that 31% of COVID ICU patients suffered thrombotic complications. These problems can unexpectedly pop up in people who had completely recovered from COVID.

A global survey tallied 205 different symptoms across 10 different organ systems that can persist after COVID infection has cleared. Typically, these manifold long COVID symptoms do not appear in isolation, but in multi-symptom clusters. A long hauler typically has several of these problems at a time.

While it is estimated that overall, 10-30% of COVID patients become long haulers, reports on the number of people suffering long COVID vary widely. Depending on the report, anywhere from 30-90% of COVID survivors suffer long term health problems. And even at the lower end of that range, 30% of over 330 million people world-wide who have been infected is a very large number. It represents an enormous personal toll in terms of lost health and diminished quality of life. Some of these reports are summarized below.

  • Half of 70,000 hospitalized UK COVID-19 patients experienced long-term complications, according to a study published in July. Complications occurred regardless of age group: For instance, 25% of adults aged 19-29 developed complications, as did 33% of those aged 30-39. Complications affecting the kidneys and respiratory system, liver injury, anemia, and arrhythmia were the most common.
  • Many COVID-19 survivors require extensive and prolonged rehabilitation. An European study found about one-third of 1,837 non-hospitalized COVID patients (i.e., those with mild disease) needed a caregiver three months after their symptoms started.
  • In April the CDC reported in its Morbidity and Mortality Weekly Report that 69 percent of nonhospitalized adult COVID patients in Georgia required
  • one or more outpatient visits 28 to 180 days after their diagnosis.
  • A study published last February in the Journal of the American Medical Association found that roughly one-third of 177 people who had mild COVID disease not requiring hospitalization reported persistent symptoms and a decline in quality of life up to nine months after illness.
  • 70% of people hospitalized for COVID-19 in the UK had not fully recovered five months after hospital discharge. They averaged nine long COVID symptoms requiring continued medical care.
  • A study in South Korea found that 90% of patients who recovered from acute COVID experienced long-term side effects.
  • According to a report in the journal, Lancet, 75% of people hospitalized with COVID-19 in Wuhan early in the pandemic, reported continued problems with fatigue, weakness, sleep problems, anxiety and depression six months after being diagnosed with the disease. More than half also had persistent lung abnormalities.

Data like these have been commonly reported around the world, pointing to a more chronic and expensive health problem than seen with the flu or common cold, which often is caused by different coronaviruses. A July 2021 article in Scientific American talked about how all of this indicates that long COVID will cause a “tsunami of disability” that will affect individual lives as well as create enormous strain on the health system. Consider the numbers: More than 60 million Americans (this is an underestimate since many COVID cases are not reported) have been infected with the CoV-2 virus. Therefore, if only 30% of these suffer long COVID, we are talking about 20 million long haulers and counting.

The related health care and disability costs of all of this are also still being calculated. How many “long haulers” will not be able to return to work for months, or at all? How many will need short-term disability payments, and how many will become permanently dependent on disability programs? As increasing numbers of younger people become infected, will we see a generation of chronically ill? This then moves us to consider the economic and financial cost of long COVID, which will be the topic of the next installation in this series.

Stay tuned.

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Has Omicron Rendered Vaccines Ineffective?

Early in the pandemic, when we realized that the CoV-2 virus was quickly producing mutated progeny, some of which were becoming more deadly and transmissible, some (including your humble blogger) warned that viral mutation could feasibly give rise to a variant that ignored immunity to previous iterations of the germ—in other words able to ignore the current vaccines. We have arrived—almost.

The so-called omicron variant partly avoids immunity conferred by the current vaccines (and by prior infection), meaning that we are seeing “break-through” infections in fully and partially  immune people. Popular news sources are running headlines declaring that vaccinated patients with COVID are filling hospital beds, leading many to leap to the conclusion that the vaccines have failed.

But, that is not fully accurate. Many vaccinated people are indeed getting infected with omicron, yet the vaccines are still quite effective, and much better than no vaccine. Let me explain.

First, about two-thirds of Americans are vaccinated—a definite majority of the population. This means that for a hypothetical virus that can fully evade immunity, there are more vaccinated than unvaxed viral “targets” available; meaning more vaccinated than unvaccinated people will be infected. The reality, however, is that the vaccines are still partly protective so that many vaccinated people still catch omicron COVID. Yet, compared to vaxed people, unvaccinated people remain at significantly greater risk of infection, hospitalization, and death. Numbers in my State of Wisconsin, bear this out.

Currently, 69% of the State adult population is vaccinated. According to the latest data* (as of January 15, 2022), out of 100,000 vaccinated people, 1573 caught COVID, 18.5 were hospitalized, and just under 4 died. In contrast, out of 100,000 unvaccinated people, 4,746 got infected, 176 were hospitalized, and 51 died. In other words, many more unvaccinated adults are feeling the effects of COVID, despite representing only 30% of the State population. Clearly, there were breakthrough infections in vaccinated people, but just as clearly, unvaccinated people fared way worse than they would have if they had the shot.

Yet, the headlines persist, proclaiming things like, “Similar numbers of vaccinated and vaccinated people hospitalized for COVID.”   Does this not show that the vaccines are no longer effective? Not at all. Because many more people are vaccinated and partly susceptible to the virus, more and more vaccinated people are showing up with infection, but at a much lower rate than unvaccinated people do. The graphic below illustrates how this works.

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The benefits of the vaccines also are reflected in national and world-wide numbers. The US has one of the lowest vaccination rates among developed countries such as the UK, Canada, Norway, Denmark, etc. And despite omicron’s “milder” nature, which means it kills fewer people but still kills, the COVID death rate in the less vaccinated US is greater than seen in more vaccinated countries, attesting to the efficacy of the shots. Also, new hospital admissions in the US have now reached an all-time high and far exceeding hospitalization rates in better vaccinated countries. Current data from New York State shows that hospitalization among the unvaccinated is 14x higher than among fully vaccinated people.

All of this demonstrates how effective the vaccines remain at preventing infection, hospitalization, and death from omicron-driven COVID. Places with higher vaccination rates, such as the UK and Canada, are not experiencing an increase in base case rates of patients admitted to the ICU or deaths, even with omicron cases skyrocketing. The US is.

Get your Fauci boo boo.

*Note on Wisconsin State data sources: State data mentioned here are from the Wisconsin Department of Health Services, Public Health Madison and Dane County, and the Wisconsin Hospital Association as reported Jan 15, 2022 in the Wisconsin State Journal.


The Long Haul, Part 1: What Long COVID Is Like

This is the first part of a multi-part blog series on long term morbidity associated with COVID-19 infection (how many parts there will be in the series remains to be determined). When public health scientists assess the impact of a disease on society, they consider both mortality as well as morbidity. In fact, the CDC’s primary assessment of US health is a publication called the Morbidity and Mortality Weekly Report. This blog series was prompted, in part, by repeated assertions by vaccine nay-sayers that since the mortality of COVID is only about 1.5% of those infected (they usually cite a false and much lower mortality rate), the vaccines and mandates are unnecessary. To that naive statement I make three points that the nay-sayers typically ignore:

  1. The Spanish flu had a similarly low mortality rate as COVID-19, but in just 24 weeks during its second wave, it killed more people around the world than were killed in the 10 years of WWI and WWII combined. Hence, just looking at the percent of infected people who die does not tell the whole story if you do not also mention the total number of people infected. One percent of a billion people is a very large number, for example.
  2. By focusing only on the low mortality rate, the vax nay-sayers are engaging in a logical fallacy called “confirmation bias.” That is, they totally ignore the statistics that do not support what they want to believe. What they ignore here is the cost incurred by disease survivors, or the morbidity. Morbidity rates usually swamp mortality rates and, as we shall see in this blog series, long COVID can cause a disproportionate cost to individuals and society in terms of damaged health, lost productivity, increased burden on health systems (which also affects care of critical non-COVID patients) and insurance payors, lost earnings, interrupted careers, and even delayed deaths that are not attributed to COVID, such as suicide, which I discuss below.
  3. Last December, just before the vaccines first rolled out, I reported that COVID-19 deaths had become, by far, the number one killer in the US, which contradicts the “negligible death rate” narrative of the nay-sayers. At that time COVID deaths far outpaced deaths due to cancer and heart disease, the previous top two causes of death in the US. That high COVID death rate dropped because of the vaccines. These facts put the lie to anti-vaxer’s claims that we do not need vaccines or public health mandates because the death rate from COVID is low. The COVID death rate had become very high, but is now much lower precisely because of the vaccines and mandates.

In this post, Part 1 in the series, I relate what long COVID is like to some long haulers. In future posts, I will focus on the costs of long-term COVID, and on the specific devastating health effects long-haul COVID can have on the neurological system, on the kidneys, lungs, and on new-onset Type 1 diabetes. And I will discuss what we have learned about the causes of long COVID and how to treat or manage it.

What is it like for long haulers? I began this blog in April 2020, and one of the first posts I made was about the experience of an emergency room doctor who was on the front lines of the early pandemic working in an ER in NYC, which was very hard hit by the pandemic. She caught the disease and spent a couple of weeks in the ICU recovering from it. But, something was not right with her after she was discharged from medical care, and she was re-admitted to an in-patient psychiatric unit to treat her mind. After a few weeks, she was released to convalesce at her sister’s home. But, she was still not right in her mind and eventually shot herself in the head. Her suicide was not counted as a COVID death. There have been other post-COVID suicides since then.

There are the recent post-COVID suicides of Texas Roadhouse CEO Kent Taylor and "Dawson's Creek" writer Heidi Ferrer and several others, which reveal a heightened risk of suicide as a sequelae of long COVID.

Sometime early in the pandemic, a healthy, young journalist who had recently graduated from journalism school also caught the disease. She eloquently wrote about the ordeal, which began in full four weeks after she had been diagnosed and two weeks after she no longer tested positive for the virus. She wrote how her body shook for five days before checking into a North Carolina hospital not knowing what was wrong. She wrote that two nights before going to the ER, and after being “cured” from COVID-19, she was jolted awake by what felt like a “brain zap.” She staggered into the hallway which she described feeling like it was on a funhouse tilt. She said she felt like she was in a Salvador Dali painting, “distorted and oozing.” When she tried to speak to her husband, the words came out drowsy and slow. I personally found the description of her feelings interesting since a friend of mine who had experimented with drugs in her earlier life once told me about tripping on LSD and feeling like her “face was melting like in a Dali painting.” For the young journalist, long COVID was somewhat similar to the experience of my friend on LSD.

Like 10-30% of the ~200 million, globally (a large number), who have survived COVID-19, the journalist did not get better after she was declared to be COVID-free,  and in fact she said that what came next was much worse than the disease. After a month of non-stop post-COVID malaise, she found herself in the emergency room complaining that she had a “shaky, electric feeling” in her stomach, and that she could not think or sleep. Eight months later the waves of illness had not let up. She was one of the early cases of long COVID, which we now know occurs in 10-30% of COVID survivors (although one study from Italy claimed that >50% of COVID survivors experienced symptoms at least four months after their infection).

The journalist wrote in July 2021, “Since December (2020), I've seen 15 specialists, received eight scans, visited three ERs and--even with insurance--spent $12,000 seeking a return to normal life. Since February, I moved across the country (from North Carolina) to receive treatment from a post-COVID recovery clinic at (the) Keck School of Medicine at the University of Southern California. The clinic refers its patients to specialists depending on their symptoms and provides a social worker. I receive weekly treatment from a physical therapist, occupational therapist and neurologist there.”

“I've had more than 50 symptoms ranging from cognitive impairment, insomnia, vertigo, extreme light and sound sensitivity, and fatigue, to convulsion-like shaking, slurred speech, hair loss, muscle weakness, anxiety.” She said that she was too “foggy” to read or even to watch TV news, which was her occupation. She was unable to write for six months, and had not had a symptom-free day since November 6, 2020, the day she tested positive for Covid-19. Most of these symptoms occurred simultaneously.

She writes on, “Before my illness, I never had any thoughts about suicide. This changed after I got sick. I'm no longer in this dark place, but the months it held me hostage I inched closer to the edge than I ever wished to be. As my brain fog intensified, I developed such a palpable anxiety, it brought with it new compulsive behaviors like "trichotillomania," or hair pulling. The days blended into one dream-state. I had only what I can describe as brain zaps. I'd wash my hair, forget, then wash it again. The further I slipped away from reality, the deeper my depression became.”

“I found myself researching death-with-dignity laws. I learned that Northern European countries have some of the most lenient.” She entertained suicide for the first time in her life. Other post-COVID patients have also described having thoughts of suicide and some have acted on that.

The experience of this journalist and a few million others like her quickly became noticed anecdotally by the medical establishment and the patients were referred to as “long haulers.” Their constellation of symptoms became known as “long COVID,” or more formally Post-Acute Sequelae of COVID-19 (PASC). As long COVID became increasingly recognized, the medical establishment realized that it was something entirely new and that they had little clue on how to deal with it other than try to manage the myriad symptoms, now numbering at more than 200. We now know that long haulers can suffer months of “brain fog,” persistent headaches, chronic fatigue-like symptoms, breathing problems, lung failure (sometimes requiring transplants), new-onset diabetes, depression and/or anxiety, dizziness, muscle and joint pain, and more. These occur in 10-30% of old and young infected people, and even in those who had mild COVID-19.

Medical science is slowly catching up, but progress is slow, not for lack of effort, but simply because medical research takes time. The very recent FAIR Health study of COVID-19 patients, the largest to date, analyzed health records of nearly two million people who have been infected with the virus in the US and found that hundreds of thousands have sought care for new health conditions after their acute illness subsided. New research points to neuropsychiatric changes in Covid-19 survivors potentially due to brain inflammation or to a disruption of blood flow to the brain. Then there are other theories, partly borne out by an Oxford study, that the virus affects serotonin and dopamine neurotransmitters, affecting brain function and physiology. A recent case published in the Journal of Psychiatry Neuroscience and Therapeutics reported that "autoimmune-mediated psychosis" caused a 30-year-old without previous health or psychological conditions to become delusional after recovering from COVID. In response to this increasing concern over long COVID, NIH launched a large nationwide study of long COVID and recently  awarded $470 million to New York University Langone Health. This NIH REsearching COVID to Enhance Recovery (RECOVER) Initiative aims to learn why some people have prolonged symptoms or develop new or returning symptoms after they recover from the acute phase of infection.

In future posts in this blog series, I will cover in more detail what we have learned to date about long COVID. Since the data keep coming in, I cannot predict when this series will end.

So, stay tuned and please ask questions.

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Average US Life Expectancy Drops In 2020

There remain people who try to explain away COVID-19 mortality as due to underlying conditions like diabetes or asthma. This is like claiming that someone with diabetes who was run over by a bus was felled by the diabetes, not the bus. I continue to point these skeptics to two actuarial studies done in the US and UK that showed that COVID-19 was causing much earlier than expected deaths in patients with these and other comorbid conditions. All of this was later confirmed in another report published in the Journal of the American Medical Association. In other words, research has well established COVID-19 as the cause of death in most patients with comorbid conditions.

If something causes the death rate to increase, it is reasonable to expect life expectancy to decrease. This is what has happened in the US during the pandemic. Two recent studies reveal just how much of a toll COVID-19 has taken on life expectancy in the US in 2020.

An updated study published in mid-June (originally published in January) in the Journal of the American Medical Association by researchers from the USC School of Gerontology and from Princeton University reported that in 2020, the average US life expectancy dropped by 1.3 years (from 78.74 to 77.43 years). It also reported that compared to white people, the reduction in life expectancy was three times as large for Latinos and twice as large for blacks. The research was based on data obtained from the CDC, the Census Bureau, and the US Vital Statistics System. The study warned to expect a continued decline in life expectancy in 2021.

A separate study published around the same time in the British Medical Journal, confirmed the racial disparity in life expectancy due to COVID-19, and indicated that the pandemic took a much greater toll on life expectancy in the US than in other high-income nations.

The effects of the coronavirus pandemic on life expectancy include deaths directly attributed to COVID-19, as well as those due to pandemic-related reduced access to health care. It is important to understand that these factors are partly offset by a simultaneous reduction in deaths from other causes such as other infectious diseases and accidents as Americans sanitized more and traveled less. In other words, we saw a reduction in deaths due to common causes, which should improve life expectancy. Therefore, the fact that life expectancy dropped, rather than improved, makes the overall decline in longevity more alarming.

Increased mortality represents only part of the burden of COVID-19; for every death, a much larger number of infected individuals experience serious acute illness that requires hospitalization, many more face long term health and life complications that drain personal finances, stress health resources, and affect ability to work at jobs.

Greater than 95% of hospitalizations and >99% of COVID-19 deaths now occur in unvaccinated people. Almost all of this is preventable with vaccination.


What Is Going On In India?

The situation. India is in the throes of a second major Covid-19 surge that has hit faster and harder than the first wave did. That is often how viral pandemics behave. This catastrophic second wave came after a strict lockdown of the country in early 2020 following the first wave. In January 2021 India’s Prime Minister Modi declared that the lockdown had succeeded and that they had defeated the virus, and he re-opened the country. Until March, India was recording barely 13,000 new COVID-19 cases a day, fewer than Germany or France, and a drop in the bucket for a nation of 1.4 billion people. A few weeks after Modi’s victory declaration, however, daily cases began slowly climbing, then in late March they exploded, becoming a vertical line rather than an upward sloping curve. By mid-April India reported 315,000 new cases in one day, setting a world record. Yesterday (May 5) India set yet another record with 3700 daily deaths, according to the Johns Hopkins University tracker. The case and death rates are still climbing. Today, almost 50% of the world’s new cases come from India, according to the WHO.

India has reported 2,000-4,000 COVID-19 deaths a day for several weeks now. Since the country’s health infrastructure is poor, this likely represents a significant undercount of the mortality. As of April 30, the official total death count was around 200,000. However, the official tallies do not reflect the thousands in poor and rural areas who cannot get medical care and die at home and are not counted. For example, in just one day at one crematorium in Bhopal, workers cremated 110 COVID-19 victims, but the official total death toll for the city was just 10. Experts suspect that the total death toll in India is 1-2 million.

The second wave of the pandemic also has overwhelmed hospitals across India. Securing a hospital bed, even for the critically ill, is nearly impossible. Hospitals put up signs declaring they have no beds, and families in large cities have to search for days to find beds, often hundreds of miles away. Sick people die on the roads outside hospitals and in traffic jams created by ambulances ferrying critically ill patients in search of a bed. There are images of patients gasping for oxygen while waiting to see a doctor.

Because getting admitted to a hospital is so difficult now, patients who are admitted are much sicker than in India’s first wave. The average temperature readings of second wave patients are 2 to 3 degrees higher than they were during the first wave when temperatures averaged 100-101 degrees Fahrenheit. Blood oxygen levels of recently admitted patients run lower than they did last year meaning the patients are more critical and in greater need of oxygen. The patients are also younger this time around, between the ages of 35 and 45, and often without other pre-existing conditions.

Critical healthcare necessities are in short supply in India, from intensive care beds, medicine, oxygen, and ventilators. Delhi hospitals have tweeted messages appealing for oxygen. At one Delhi hospital, 20 critically ill patients died after the hospital’s oxygen delivery was delayed seven hours. Families are often told that they have to provide their own oxygen for hospitalized family members or take them home. In a video post, the director of a hospital said they had 60 patients in need of oxygen with only two hours of supply left.

Help for India has been offered by several countries, including the US, UK, Germany and even from India’s archrival Pakistan, which offered ventilators, oxygen supply kits, digital X-ray machines, PPE, and related items.

Bottom line. This is a snapshot of what things look like in India now, almost a year and a half after the virus first introduced itself to the world. In January, India believed that its strict lockdown measures had defeated the virus. They did not. How the more deadly second wave of the virus and disease appeared, almost overnight, will be the topic of the next blog post. It should concern all of us, because it could also happen here.

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Increasingly Contagious And Lethal CoV-2 Variants Are Popping Up Around The World

In September, the UK noticed a coronavirus variant that has a surprising number of genome mutations, including eight point mutations in the spike protein, which is the viral antigen targeted by most of the vaccines. In just a couple of months, the variant became the prevalent cause of COVID-2 in the UK, meaning that it spreads faster than other iterations of the virus. It also has been found in a few pockets in the US and is expected to become the dominant strain here by March. It appears that the variant is 30-50% more infectious in all age groups (down from the early 70% estimate in December). Fortunately, all indications are that the two mRNA vaccines being rolled out by Pfizer and Moderna are effective against the variant (expect two more vaccines based on different technology platforms soon, from AstraZeneca and J&J).

The bad news is that British public health officials just warned that the virus variant is just not more contagious, it also is 30-40% more lethal. Out of 1000 60-year old patients infected with the UK variant, 13-14 would be expected to die, compared to 10 deaths in patients infected with the previous virus. This warning was based on four separate UK studies.

Related, but not identical, viral variants also have appeared in South Africa and in Brazil. These variants also seem to be more contagious and, not surprisingly, share some of the same spike protein mutations as the British variant. There is no word, yet, on the lethality of these variants. However, three lab studies in South Africa have raised concerns that their variant might be resistant to the current vaccines. Pfizer studies found that their vaccine protects well against the British variant, but the South African variant seems to be more resistant to the two vaccines currently in use. It too has quickly become the dominant virus strain in that country and has been found in 22 other countries. It has not yet been found in the US, but give it time.

These new virus variants that are more contagious and more lethal are appearing in countries where a significant percentage of people have already built some immunity to the original CoV-2 strain. This raises concern that our immune responses can provide natural selection pressure that favors virus variants that avoid the specificity of our immune response. In other words, our immune systems and the vaccines might be driving the emergence of more contagious and deadly forms of the virus. If so, this would necessitate adapting the vaccines to meet the variants and establishing a regular vaccine schedule with continually changing vaccines like we do now for the flu virus.

The CEO of BioNTech, the German biotech company that spent a decade developing the mRNA vaccine platform used in Pfizer’s vaccine, said it would take only six weeks to design a new vaccine specific for new variants in the spike protein. The platform is in place and all they would need to do is swap out the spike protein mRNA for the new variant sequence. Then it would take some time to produce the new vax and get it into arms. But, again, that is similar to what we do each year for the new flu strains that pop up annually.

Hopefully, the new vax technology will let us develop new vaccines as fast as the virus mutates.

The race is on. Bet on the new vax technology, which I earlier christened, BioX.


400,000 Total COVID-19 Deaths In A Year

Shortly after Thanksgiving, I wrote in these pages how the post-turkey surge moved COVID-19 to the top cause of death in the US. I reported that the disease was killing more than 14,000 people a week, above the ~12,000 killed weekly by the former top killers, heart disease and cancer.

Grim.

It is getting grimmer: Now the CDC estimates that 92,000 people will die from the disease in the next three weeks. That is almost 31,000 deaths a week, more than double the death rate in early December. And, a study just published in the Proceedings of the National Academy of Sciences reported that the average life expectancy in the US in 2020, dropped by more than a year. The study was conducted by researchers from Princeton and the University of Southern California using data from the Institute for Health Metrics and Evaluation.

If the pandemic didn’t take place, the study authors note that a person born in 2020 would, on average, live to about 79 years. The virus shaved almost 1.22 years off of that average life span. Black and Latino populations were projected to suffer significantly greater declines in life expectancy compared to White populations.  Reduced life expectancy among minorities was projected to be about triple that for White populations: life expectancy is projected to be 0.73 years lower for the White population, 2.26 years lower for the Black population, and 3.28 years lower for Latinos.

While 400,000 deaths is very tragic, it is a mere drop in the bucket compared to the many more COVID-19 patients who suffer long term, or even permanent morbidity. More on that later.

Shifting Topics: From June to November, Public Health England, tested thousands of healthcare workers in the UK. They reported that out of 6,614 healthcare workers who tested positive for COVID-19 antibodies, there were 44 reinfections. That is a good rate of protection against reinfection, but the reinfection rate still is surprisingly high.

This means that even though you had the virus or even were vaccinated, you might still be able to pass it on. What should you do?

  • Still get the shot.
  • Still mask up.
  • Still socially distance.
  • Still wash your hands.

In other words, be a good neighbor.

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The Lesson Behind The Long Recovery From COVID-19 For A Young Physician Assistant

This is an update to a story published on March 10, 2020 by MedPageToday. You can read the original piece here.

In March, James Cai, a physician assistant and New Jersey's first COVID-19 patient, made headlines for warning the country that even young, healthy 32-year-olds like himself were vulnerable to the virus. He came down with the disease in early March and was admitted to the hospital on March 3. Because the disease was so new, he was worried that he wasn't getting the right treatment at the hospital, so he took his case to Twitter.

In the beginning, he was treated like he had a serious case of the flu. He received high-flow oxygen, chloroquine, and lopinavir/ritonavir (Kaletra), and was one of the first patients to receive remdesivir under compassionate use approval. He was able to connect with Chinese physicians who had experience with the disease, and a Chinese-American doctor translated the Chinese protocols into English for Cai's New Jersey doctors.

He was discharged on March 21, but still needed supplemental oxygen -- especially at night. A month after his discharge he went back to work as a physician assistant, but only virtually and half-time. But even by mid-summer, Cai was still seeing impairments in his oxygen saturation and activity levels. His O2 saturation was 97% during the day, which is good, but it dropped to 90% when he lay down to sleep, necessitating the oxygen supplement. He tired very easily and was unable to run and exercise like he did before. Through that time, he was taking dual anticoagulant therapy of Xarelto and aspirin.

In late summer, things started to look up. On August 21, he confirmed that he could sleep through the night without oxygen, but the results of his latest chest CT showed permanent fibrotic lung damage in his left lower lung. As of December, he was still testing positive for coronavirus antibodies.

We still do not know why some people, especially young, healthy people can be so hard hit by the virus while others are not. Why did Cai become so ill and suffer permanent lung damage, while a couple of my nearly 70 year old friends caught it and had milder, temporary symptoms? It will be a while before we understand this.

This story also illustrates the folly of just looking at mortality numbers when assessing COVID risk. The death rate for COVID-19  is low, about 1% or less of people who get infected die from the disease, so some folks cite that low death risk and take a cavalier approach and avoid social restrictions designed to slow the virus spread. By focusing on that simple statistic, they ignore the fact that COVID is now the leading cause of death in the US by far and has killed 10 times the number of people who are killed by seasonal flu. The devastating 1918 Spanish flu also had a very low death rate, but in just 24 weeks, it killed more people around the world than were killed in the 10 years of WWI and WWII combined!

And those people who cherry pick their statistics to justify their careless behavior ignore the greater number of people like Cai who survive the disease, but suffer long term and even permanent health problems. Is it really worth the risk of permanent lung damage to exercise your freedom to not wear a mask?


COVID-19 Is The Leading Cause Of Death And Accelerating

Reuters reports that last week 17,000 people died from COVID-19, far surpassing the death rates of the former top two killers, heart disease and cancer, which kill about 12,000 people each week. There were 15,500 COVID-19 deaths the previous week, so the post-Thanksgiving surge is growing.

The Dakotas and Iowa reported the most deaths per capita last week, while Rhode Island, Tennessee and Ohio had the highest number of new cases per capita. And according to the Johns Hopkins Tracker, the US has passed 300,000 total deaths.

Across the US, ~12% of CoV-2 tests came back positive, compared to 10.5% the previous week. 32 states had a positive test rate of 10% or more with the highest rates reported in Iowa and Alabama at 50%.

One conclusion from these data is that states that have the most lax restrictions, or most resistance to common-sense safe practices are bearing the brunt of the pandemic.