Covid-19

New information keeps appearing; this Diagnosis123 section was last updated 1/19/2023.  Recommendations try to be consistent with CDC & WHO.

What’s new with Covid?

• Lots of new Omicron sub-variants keep appearing. BA.5 was the main one to appear this autumn, but now we have BQ.1 and BQ.1.1., and the newest of all, XBB.1.5. The alphabet soup keeps expanding
• But for the moment — indeed, throughout the ongoing emergence of new variants up to now — it doesn’t seem to mean much in practical terms:
  • The new variants have mutations which help them spread easier. But they don’t seem to be causing more serious disease
  • The new “bivalent” Covid booster also covers Omicron variants as well as the original strain. It’s always hard to know how well a new vaccine will really work without waiting months; the best idea we can get earlier is by measuring how well it generates neutralizing antibodies, but other aspects of our immune system, like cell-mediated immunity, seem to be enhanced just fine.
  • Vaccinations still prevent death and severe disease; indeed, virtually everyone who gets hospitalized or dies from Covid hasn’t been vaccinated. The antiviral medications Paxlovid & Remdesivir still work, and save lives. However, monoclonal antibodies don’t work against the new variants, nor does the preventive shot Evusheld. This is most unfortunate for people severely immunocompromised, who the vaccine doesn’t protect well.
• What’s the difference between a “variant” and a “strain” ? A “strain” of a virus acts more like an original, new virus, although different strains tend to be very similar in terms of causing disease & responding to treatment, for example Herpes-1 and Herpes-2. A “variant” is only a slight change from the original, less so than a “strain”. All strains are variants, but not all variants are strains.
• Some experts argue that repeated boosters shouldn’t be mandated for younger people, under 30. That’s because the real benefit is very minimal, the real dangers are also minimal but still exist, so it’s not right from a public health perspective to make boosters a condition for school or employment. For older people, especially over 65 (even 50), boosters still give added protection from serious illness, hospitalization, and death. The CDC still recommends boosters for everyone, which is not the case in the UK and many European and other countries.
• There are reports of people who receive the anti-viral medication Paxlovid® who seem to get better following the 5-day treatment course, but then get worse. Some test Covid-negative, but then revert to positive. It’s unknown what causes it, or what to do about it, but there are no reports of increased hospitalizations or deaths. The extent to which this happens may be overestimated. The same thing can happen with Covid itself, that’s untreated.
• Again, the purpose of all Covid treatments and vaccines is to prevent hospitalization & death, and they work very well in that regard. As such, anyone for whom they’re recommended should seek them. After all, preventing death is not a bad thing.
• Long Covid — lots of confusion about the definition, lots of unverified assertions on the internet. A new analysis of 54 studies of people infected in 2020-2021 (>1 million patients) found that persistent symptoms after Covid occurred in about 6.2% of people, and about lasted 9 months for those sick enough to have been hospitalized, about 4 months for those not that sick. Main symptoms were fatigue, lung symptoms, and cognitive symptoms (“brain fog”). These patients were infected before the Omicron strain, so it’s hard to know if the numbers are still relevant.

What follows is basic information & background about Covid, from prior posts.

Covid-19, or simply “Covid,” stands for Coronavirus Disease 2019.  It’s caused by the germ “Severe Acute Respiratory Syndrome Coronavirus 2,” abbreviated SARS-CoV-2, which is a type of virus of the group Coronavirus (see Differences Among Germs).  Other coronaviruses cause a common cold.  In 2002 a very severe coronavirus then called SARS (now SARS CoV-1) killed 25% of people who got it, mainly in south China and Southeast Asia.  Another coronavirus Mid-East Respiratory Syndrome (MERS) evolved from camels in Saudi Arabia and killed 35% of people infected.  But even though SARS & MERS were spread person-to-person, they never spread far.  SARS CoV-1 has disappeared; MERS mainly occurs on the Arabian Peninsula.

SARS-CoV-2 began in bats & transformed itself to spread to people and cause Covid, which has spread throughout the world (a pandemic).  In the U.S., about 1-2% of people with Covid die (mostly of lung complications), but the problem is that it’s very contagious, so that adds up to lots of deaths.  Among people over 65, 7%-10% may die; 5% among those who are obese, or have diabetes, chronic heart or lung diseases, kidney failure, late cancer.

Most people with Covid have mild symptoms.  Many have no symptoms at all, but can still spread it.  The younger the person, the less chance of severe disease, but some can still die.  Some people refer to it as “just a bad flu,” but no recent “flu” ever killed over 500,000 people in the U.S. in a year.

There’s a theory that SARS-CoV-2 actually originated in a Chinese government laboratory, perhaps from a bat brought in for research, & then escaped. There’s no thought that it was created on purpose (aside from conspiracy theorists). In my mind, it doesn’t really matter. Of interest, smallpox virus has been eradicated from the earth since 1980, but is still kept in U.S. and Russian military labs for vaccine research (surely just in case the other side weaponizes it, since smallpox vaccine is no longer given anywhere).

Symptoms  —  The most common symptoms of Covid are fever, cough, body aches, and fatigue.  An unusual and somewhat common symptom is loss of sense of smell (one mom couldn’t smell her baby’s dirty diapers!), but this seems much less prevalent with the newer Omicron variants.  There are many other possible symptoms like sore throat, diarrhea, and more, but they don’t point as much to Covid as the other symptoms above.  The most severe symptom is shortness of breath; that’s who gets admitted to hospitals. See also Covid Symptoms.

Symptoms begin 2-14 days after becoming infected, usually within a week.  Mild cases last 1-2 weeks, but perhaps a third of people feel sick longer.  An important point to keep in mind is that severe Covid lung damage is usually delayed until after the first week of illness, & then keeps getting worse.  Everyone with Covid should have somebody to keep daily contact with them, in case they suddenly become much sicker.

There are several unusual manifestations of Covid.  Blood clots have been noted, in the lungs, or as a stroke (even in young people).  There have also been a variety of heart problems.  Toes turning red & painful is rare, but points strongly to Covid.  Also rare is generalized inflammation of many organs occurring in children (without lung involvement!).

There’s also phenomenon called “Long Covid,” or Covid “Long Haulers.” This refers to a variety of ongoing symptoms that persist after recovery; sometimes they start weeks after having gotten better, & rarely might they begin without having even felt sick with the original Covid infection. Long Covid includes fatigue, mental sluggishness, sleep difficulty, fevers, anxiety, depression, and more. Some reports say vaccination can “cure” Long Covid, but this hasn’t been studied systematically.

Diagnosis is made by a variety of Covid tests.

Treatment –  If someone with Covid feels short of breath, they should go to an emergency room.  If they can breathe OK, they should stay at home.  There’s no treatment to help them get better quicker.  Acetaminophen (Tylenol) or other over-the-counter medicines can help with fever and aches.  Nothing works very well to help the cough.  Drinking lots of fluids is important.

There are two broad types of medications to treat Covid: antibodies, and anti-virals. The latter work like antibiotics do against bacteria, to kill the virus outright. The antibodies are given by IV infusion, to patients not sick enough to be hospitalized; they should be given within 10 days of symptoms. The new Omicron variant is resistant to the first ones invented, but not to the most recent antibody Sotrovimab (Xevudy®) [although a recent report from Australia found possible resistance to it in the earlier Delta variant, so anything could change].

There are 3 anti-viral medications, all must be given within 5 days of onset of symptoms to work:

• Nirmatrelvir + Ritonavir (Paxlovid®), pills, decrease hospitalizations and death by 88%. There may be many drug interactions with other medications
• Molnupiravir  (Lagevrio®), pills, decrease hospitalizations and death by 30%
• Remdesivir (Veklury®), given by IV for a few hours a day for 3 days. Decrease hospitalizations and death by 87%

For patients sick enough to be hospitalized, the most important treatment is keeping their oxygen levels high enough until they get better on their own.  A variety of medications are used for patients in the hospital, and may help somewhat.  The main medication is a steroid (usually dexamethasone), but this can make mild cases worse, so nobody should ever take it on their own.

In terms of Isolation & Quarantine, the CDC now recommends 5 days from when symptoms began, as long as fever has disappeared for at least 24 hours without taking medications for it. The same goes for people with a positive Covid test and no symptoms. Wear a mask & don’t travel for another 5 days.

Transmission –  SARS-CoV-2 is essentially transmitted in the air.  The most risk is standing less than 6 feet from someone, although if the person is talking fast or loudly or singing, huffing & puffing, etc., the virus can spread farther.  Also, the virus can remain suspended in the air for several hours, so simply being in a crowded indoor location for a while can be risky.  Covid is probably not spread very often by objects, so deep cleaning is surely not worth the effort or expense, although hand hygiene is strongly recommended (washing for 20 seconds, or rubbing well with alcohol-based gels for 15 seconds).

Prevention – Staying at least 6 feet away from people & avoiding crowds, especially indoors, is probably the most important measure.  Wearing a surgical mask or face covering hardly protects you, but masks are most important for protecting others.  If a person has Covid but doesn’t know it (30% to 40% of infected persons have no symptoms), the mask stops viruses from traveling far & getting up in the air.  The main mask for self-protection is the N95, worn by health workers dealing directly with Covid, which can now be purchased commercially. If you get one, only wear it indoors where people are around, which is when it’s most useful, so it doesn’t get worn out. I googled “N95 3M” [3M is a legitimate manufacturer], and found a box of 10 for $20. The KN95 mask is slightly inferior to the N95, but much superior to surgical and homemade masks, and is a little cheaper.

The CDC’s recommendations change fairly often. This has resulted in considerable confusion in public. We should realize that Covid is new, things keep changing as the virus mutates and changes (see Variants below). Newer variants can break through vaccine protection to cause infection, usually without making the person sick at all, but still able to spread it. The main danger here exists for people with medical conditions which interfere with the vaccine, like those with active cancer, or taking medications which block the immune system. Their vaccines don’t work as well, and they can get very sick from Covid. It’s very important for everyone to realize that Covid is new, nobody can predict the future, so we all need to face this threat maturely.

Vaccines  —  There are several available.  They have brief side effects; dangerous reactions have been publicized but are exceedingly rare.  All have been shown very effective in preventing severe disease, & especially death (which is the whole point!). 

Indeed, even if case rates may sometimes rise in different areas, the only people needing hospitalization now, and dying, are those who haven’t been vaccinated. All vaccines available in the U.S. work well in this respect among all variants found here; get whichever one is available!

One big question is how long the vaccine protection will last.  A first booster should be gotten 6 months after the initial doses. It should be one of the mRNA vaccines, Pfizer or Moderna, and doesn’t matter which the original vaccine was. A second booster is now recommended for people over 50, or those who are immunocompromised. This is based on data from Israel showing that per around every 2,000 people, during a little less than 2 months, there were about 1.5 cases of severe Covid following 4 doses, compared to 4 cases for only 3 doses. There was little if any extra protection against getting infected, and then transmitting.

There was some news in the press a year ago about strange blood clots in the brain within 2 weeks after receiving either of 2 vaccines: Johnson & Johnson, and Astra-Zeneca (not available in the U.S.). Both employ the same technology, so there may be a relationship to the clots. The clots occur in around 1-2 people out of a million who’ve been vaccinated, although all were under 50-60 years-old, and almost all were women. It may make sense for this group of people to receive other Covid vaccines. There are also rare cases of mild heart muscle inflammation in teenagers; all patients have recovered. Vaccination is recommended in pregnancy; there’s no evidence of any danger (there’ve been deaths & miscarriages from Covid itself).

In our daily lives we do things that are much more dangerous, like ride in cars and cross city streets. If vaccinated against Covid, there’s more risk in dying from accidental electrocution than the illness. The risk that a woman may die in pregnancy in the U.S. is about 1 in 7,000, which does not affect decisions to conceive. Then we can look at how many people died in a year from Covid-19 itself; for the unvaccinated, the risk is about 1 in 600. When dealing with life-threatening concerns like Covid, we should all try to think and act logically. In this case, getting vaccinated seems much more logical than not. It’s likely that the more people get vaccinated, the safer society will be in general.

Virus Variants  —  All viruses constantly mutate rapidly, making minor changes in their genes.  Some mutations provide a virus with special advantages, like the ability to spread easier, or cause worse illness.  They’re grouped into “Variants of interest” (nothing special), “Variants of Concern” (the main issues for the moment), and “Variants of High Concern” (major threats; but none exist to date).

Since autumn 2021, the main variant in most of the world has been Omicron (aka B.1.1.529). In early 2022, sub-variant of Omicron called BA.2 emerged, overcoming the effect of one treatment drug (sotrovimab, now no longer useful). Now in April 2022, sub-sub-variants of Omicron (BA.2.12 and BA.2.12.1) are spreading throughout New York (they’ve been detected in other states and countries as well). They don’t seem to cause more severe illness, but may be easier to infect. The moral is that viruses keep changing, situations keep changing.

In terms of history, the main Covid “Variants of Concern” have been: “Alpha” aka B1.1.7 (UK Variant); “Beta” aka B.1.351 (So. Africa Variant); “Gamma” aka P1 (Brazil/Japan Variant); “Delta” aka B.1.167 (“double mutant” out of India); “Epsilon” aka B.1.429 (California); Iota aka B.1.526 (New York); and Lambda aka C.37 (Peru); and Omicron aka B.1.1.529 (first appeared in southern Africa). The Greek letters were applied late May 2021 by W.H.O., to avoid stigmatizing countries by using geographical names, though the numbers are still used in research. Compared to the original virus identified in Wuhan, China, concerns are as follows:

• Easier to spread: Omicron (B.1.1.529) [spreads easier than others], Alpha (B.1.1.7), Beta (B.1.351), Delta (B.1.167) [lots easier]; Epsilon (B.1.429) [slightly easier]; probably Lambda (C.37).
• The new BA.2 Omicron sub-variant is now poised to become the dominant strain int he US, as it is in Europe. It spreads easier than its parent Omicron, likely causes same degree of illness (mild). It may escape immunity from prior infection.
• Vaccines may not work as well, but still prevent serious disease & death: Beta (B.1.351); Gamma (P1) [data here not yet clear]; Delta (B.1.167) [one dose of Pfizer/Moderna not effective against Delta; 2 doses protect]; Lambda (C.37) [concern about the J&J vaccine]; Omicron (B.1.1.529).
• Antibodies may not work well as treatment: Beta (B.1.351); Gamma (P.1); B.1.427; Epsilon (B.1.429); Omicron (B.1.1.529).
• More severe disease: maybe Alpha (B.1.1.7); likely Delta (B.1.167)
• Less severe disease: likely Omicron (B.1.1.529)
• Lasts longer in body: Alpha (B.1.1.7).

None of the variants so far seem to affect the Covid tests we do.  And none cause enough resistance to vaccine or prior infection so as to result in more hospitalizations or death. Recent data suggest that the mRNA vaccines (Pfizer & Moderna) fail in about 1 of 10,000 persons, and 1 in 500,000 of recipients have died of Covid. 

Every time Covid is transmitted, some mutations may emerge in the virus. So the more Covid spreads, the more likely that more concerning variants might arise. Thus, the more people resist vaccination & refuse to wear masks indoors, the worse the future may be for all of us.

Can you get Covid a second time?  Yes.  There are well-documented cases of reinfection, but not many.  The problem is, we don’t know how long immunity from Covid will last, since the disease is so new.  Current studies suggest it’s likely protective at least 8 months. It seems that people who’ve had Covid benefit especially well from vaccine afterwards.

We hear about “herd immunity,” which is when so many people in a population are immune, that the disease no longer spreads. But with 20% to 40% of people unwilling to get the vaccine, or unsure, herd immunity may not be possible. This is especially true right now because vaccines are not yet approved for younger children, and we have no idea what role they may play in herd immunity for Covid.

Why do scientists keep changing their advice about Covid? For the most obvious reason of all, namely, Covid is so new, we keep learning more and more. It’d be strange if they didn’t keep revising recommendations. Science and medicine are never ever supposed to know everything. New & updated knowledge is good.

Look at our own personal lives — how many people get divorced, for example. You start a new relationship, it seems wonderful, things go a little sour, you learn new information about your partner, & move on. It’s the most natural thing in the world!