Painting credit: a very talented 12 year old artist.
I still live in Covidlandia. It’s a parallel world where people acknowledge that Covid is still with us, that there is much we don’t know but keep discovering, and that it’s worth trying to reasonably protect ourselves from this coronavirus. A little extra caution, testing when symptomatic, and early treatment all help.
Covidlandia is not filled with fear, but rather a clear eyed recognition that this novel virus has changed the game, and we would be wise to keep adapting and evolving along with it. To that end I present the third monthly installment of key articles, trials, and research that caught my attention as a family doctor. January and February were popular posts. Of course it’s all too much for any one clinician to keep up with… but here is a collection of useful highlights, curated and presented succinctly with sources for those who want a deeper dive.
Politics are screwing things up and harming people
Resist the urge to react now. No playing offense or defense, just numbers. There is a definite partisan gap in Covid death tolls between counties that voted for Trump and those that did not.
I expect this difference in death rates would be even greater if we looked at actual voters rather than just the red/blue counties overall, as this mixes the two groups and dilutes trends. The picture below tells a grim story, even in 2024.
Leadership matters, and leaders who bring more death suck. Hard to argue with that, Republican/Democrat/independent/other, right? P.S. Climate change is bringing more death, too. We should vote for people trying to fix that.
Source CDC.gov:
A different analysis published in March found that people in Republican-voting states were more likely to report adverse events after receiving a Covid-19 vaccination than people living in Democratic-leaning states, suggesting that how people view their post-vaccine side effects or decide whether to report them is shaped by their political views. This pattern did not hold up for flu shots, which are more widely accepted and rarely the target of political attacks and posturing.
We already knew that after the Covid vaccines became available (and open for political hack jobs), Republicans started dying more than non-Republicans. This should make people on both sides furious, really. That study from this summer was published in JAMA Internal Medicine, and specifically found: “The excess death rate among Republican voters was 43% higher than the excess death rate among Democratic voters.”
Covid was still a thing in March, and new CDC guidelines abandoning reasonable sick precautions upset many.
I agree with this opinion written by Dr. Julia Vogel in early March in which she states:
In recent weeks, there have been an average of 2,000 deaths and 20,000 hospitalizations per week. The CDC just released the first data on the prevalence of long Covid in 2024, showing that 6.8% of U.S. adults are currently experiencing long Covid (up over a percent from the prior data collected last October), including after reinfections and among people who have been vaccinated…
By allowing known Covid-positive people to resume normal life, we shift the burden of Covid prevention to those who are at the highest risk… Instead, our governments should focus on low-effort ways to reduce Covid spread, such as setting standards for clean indoor air, testing to leave isolation (using freely available rapid antigen tests), offering high-quality masks and recommending them in public indoor settings, and mandating paid sick leave. We should improve public health communication about the risks of long Covid, long-term health impacts of Covid infection, and the ongoing risks of certain populations. Our policies should adapt to the current research and technology.
Maybe you don’t see the long Covid burden in your every day life, but as a primary care doctor I do see that 6.8% and more. Especially if we look for it, while ruling out other causes of profound fatigue, post-exertional malaise, shortness of breath, and cognitive problems in several 30 year-olds just this week for goodness sake.
Similar long Covid rates (~8%) were seen in a study out of France. Encouragingly, the prevalence dropped to 2.4% when the long Covid definition required at least moderate impact on daily activities, and dropped further to 1.2% when the definition was strong or very strong impact of symptoms on daily activities.
Spring boosters
The CDC recommends that people aged 65 years and older should receive 1 additional dose this spring (now) of the updated COVID-19 vaccine at least 4 months after the previous updated dose.
I’ve started doing this in the office, and the power of the word “should” cannot be denied. It works better than “may” in examining rooms.
And when I share that the updated shot worked 50-70% of the time for people this winter, many formerly hesitant folks hop on the band wagon for their first updated XBB dose.
Immunocompromised people may get another dose, too, and many experts recommend getting a boost every 6 months.
A guy received up to 217 Covid vaccinations
This was stunning, and chances are you’ve already heard about it. Reported in The Lancet Infectious Diseases, this erratic 62 year-old individual did afford researchers a rare chance to see what happens when the immune system is bombarded repeatedly with Covid vaccines:
From November 2019 to October 2023, 62 routine clinical chemistry parameters revealed no abnormalities attributable to hypervaccination, and SARS-CoV-2 antigen tests, polymerase chain reaction (PCR) tests, and nucleocapsid serologic tests showed no evidence of past COVID-19 infection. The man reported no vaccine-related adverse effects.
The man had more T-effector cells against SARS-CoV-2 than did a control group of three-dose recipients, and these cells were just as effective in fighting the virus after long-term overexposure. He also had a similar number of memory T cells, the progenitors of effector cells. Indeed, his levels of SARS-CoV-2 antibodies increased significantly even after the 217th dose, and the immune system's effectiveness against other pathogens was unchanged.
NO ONE should do this. But the case report does provide an almost satirical undermining of the fears the anti-vaccine forces continually stoke. Vaccines have rare and real risks, but much greater and common benefits across populations. Our bodies are constantly exposed to countless antigens from bacteria, viruses, and fungi, and our immune systems can handle the additional stimulation from a single vaccination. And perhaps 217, but never to be repeated.
The worst case scenario
It is important to live our one and only lives and not be totally alarmist about the ongoing threat of Covid. Random illnesses and health conditions will keep happening to us whether or not we live perfectly healthy lives in antiseptic bubbles. And yet we can still take reasonable precautions. We can still evaluate the risks and rewards of different situations.
I just got back from a great trip. I flew in an airplane but wore a 3M Aura mask like I always do. We gave good ventilation a consideration with restaurants, and only masked up in really tight situations. We are up to date with vaccines, and prepared to test and treat if sick. It’s all good. It was a great trip.
Living in Covidlandia acknowledges that a worst case scenario, as presented by a slightly alarmist group, but backed up with 122 legit references, is still quite possible. Even probable? Living here means keeping you guard up for a while longer until the coast is more clear, and making any Covid infection “worth it.”
A study published this month in Frontiers of Oncology added to evidence from other sources that Covid can increase the risk of accelerated cancer progression, metastasis, and death in cancer patients in general and in breast cancer patients in particular (5, 12, 13, 54, 55).
Another way to ride the waves is to keep an eye on Covid prevalence rates and act accordingly. Seasons matter. Things here are improving right now. How’s your region?
CDC Wastewater Data Tracker
Biobot Wastewater Tracker
In a large study, vaccination was associated with 30% to 50% lower risk for long COVID in all age groups.
Although the majority of people in the U.S. are vaccinated, many still grumble about it and refuse to get additional recommended boosters. So here’s yet another reassuring study published in The Lancet.
That 30-50% reduction in long Covid emerged from a powerful study of 10 million vaccinated and 10 million unvaccinated people in three European countries. I subscribe to New England Journal Watch, and I like how they interpreted this result further:
The large size of this study, inclusion of a never-infected comparison group, analysis of symptoms before the pandemic, and the study's statistical rigor provide strong evidence that COVID-19 vaccination lowers risk for long COVID. This protection is seen in all age groups, including young adults. Because young adults can develop long COVID, perhaps vaccine boosters should be recommended more strongly in this group.
Boldface emphasis added by me. I’ve consistently been advocating for this all along, and have been frustrated by thought leaders who narrowly consider the purpose of vaccination “just to prevent hospitalization and death.”
The 4 year anniversary of Covid lockdowns came and went in March
I’m pretty sure that Eric Topol M.D. lives in Covidlandia, too. In his newsletter he summed this anniversary up poignantly:
The global excess mortality has reached about 30 million lost lives attributable to Covid, and the Global Burden of Disease published a major paper this week in The Lancet on the toll it has taken for reducing life expectancy in 204 countries summarized as "The COVID-19 pandemic caused the most severe drops in life expectancy seen in 50+ years." The study did not address disability among survivors, with multiple concurrent studies reinforcing the prevalence of Long Covid in tens of millions of people.
4 years ago was probably the worst time I can remember in my life, professionally, personally, and socially. I’ll spare you the details, but suffice it to say that I am extremely grateful not to be living in March of 2020. We all go through horrible times holding a candle with hope for future joy, calm, and a life worth celebrating. As a wise man I know signs his letters:
Onward,
Iron dysregulation during and after Covid infections
A recent study in Nature Immunology suggests that patients who develop long COVID experience issues with regulating blood iron levels, including anemia, as soon as 2 weeks after the initial infection.
The study analyzed blood samples from 214 patients over 12 months, finding that those with prolonged COVID symptoms tended to have slower regulation of inflammation and iron levels after infection. This delay in regulation, along with more severe initial infections, increased the risk of long COVID.
It turns out that iron dysregulation is common after many infections, and can lead to less efficient oxygen transport and impaired immune function. The study authors propose a potential role for iron supplementation during acute COVID-19 infection and as a treatment for long COVID.
I would not run out and buy iron to take with Covid infections just yet. I’m going to check out the corners of the internet for more information about iron as a long Covid treatment. Tinkering with the human body is tricky business, and intuitive guesses are risky and often backfire. Stay tuned for a speculative deep dive on iron and Covid from me, bounded by evidence, and guided by this particular study’s discussion.
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Ok, I will take mercy on the causal reader now and stop this post here. It is only halfway done though, so anyone who wants to continue this trip through Covidlandia in March is welcome to a free trial/read over at Examined where I first published this post.
Take good care.
