The Latest on COVID-19

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I am following the latest developments on COVID-19 and our efforts to control the pandemic or to deal with it as an endemic  disease. I will update this page regularly, so if you are interested, check back often.  Older entries (back to 2019) can be found in the post titled Latest on COVID-19: Archive.

As of March 1, 2024:

Refusing to wear a mask when you have a respiratory infection and are near other people shows total disregard for their health. We have just gone through the major portion of a COVID-19 epidemic and can expect other epidemics from this and other viruses in the future. Many studies show that a proper mask will block some of the viruses, and droplets spread when an infected person coughs, sneezes, breathes or talks (Phys Fluids, Dec 1, 2020;32(12):127112). Before COVID-19, several studies showed that masking helped to reduce transmission of related betacoronaviruses, SARS and MERS (Lancet, 2020;395(10242):1973-1987).  See Masks Help to Prevent Infections with Respiratory Viruses

As of April 30, 2023:

The COVID-19 Vaccine is Much Safer than the Disease: Anti-vaxxers claim that you should not get the COVID-19 vaccine because of the vaccine’s increased risk for side effects, such as blood clots, that can cause severe disease and even death. This is unreasonable; a new study shows that the increased rate of blood clots within 60 days after vaccination over that of the general unvaccinated population is 1.4 cases of blood clots per 1,000,000 people vaccinated (J of Clin and Transl Sci, Feb 1, 2023;7(1):e55), which is insignificant. The study compared 855,686 veterans over the age of 45 who had received at least one dose of a SARS-CoV-2 vaccine and an unvaccinated control group of 321,676 people. The groups were compared by age, race, sex, body mass index and more.

Risk Factors for Severe COVID-19 Disease
COVID-19 is usually a benign disease for most people. However, some conditions markedly increase risk for severe disease and even death, and these people should continue to seek the protection offered by vaccines and boosters. A partial list of factors that increase a person’s risk for hospitalization and death from COVID-19 includes:
• high blood pressure
• obesity
• lung disease such as asthma, COPD or cystic fibrosis
• cancer
• chronic kidney disease
• liver disease
• dementia
• diabetes
• nerve damage diseases
• developmental disabilities
• spinal cord injuries
• heart disease
• stroke
• chronic infections
• weakened immune system
• organ transplant
• dialysis
• blood diseases such as sickle cell anemia
• smoking
• alcoholism
• over 65 years of age

Who Should Not Get COVID-19 Vaccines?
If you have a history of forming clots or are taking drugs to prevent clots, tell your doctor and you both can decide whether you should take the vaccine. You will be advised not to get the vaccine if you have a fever on the day of your vaccine appointment, if you currently have or suspect a COVID-19 infection, or you have a history of severe allergic reactions to any of the ingredients of the COVID-19 vaccine.

My Recommendations
I disagree with the anti-vaxers who say that you should not get the COVID-19 vaccine because of increased risk of serious side effects. The most serious potential side effect is sudden formation of venous clots, which occur in about eight percent of all hospitalized patients and 22.7 percent of patients in ICUs (Res Pract Thromb Haemost 2020;4(7):1178–1191). The data in this new study show that vaccination increases risk for forming clots by 1.4 cases per million vaccinations, which is not significantly different from the risks for the same age group in the general population.

As of January 30, 2023:

Bivalent Booster Protects Against the Most Recent COVID-19 Viruses: The U.S. Centers for Disease Control and Prevention (CDC) reports that the case count of COVID-19 in the US stands at 102,283,559 cases, including 1,107,645 deaths as of January 30, 2023.  The CDC says that you may now need to get yearly vaccinations as we do with the flu. The protective antibodies promoted by the vaccine start to drop after one month and may be gone in a year. The vaccine mutates so that you may need to protect yourself each year against a new COVID-19 variant.

The CDC reports that the bivalent COVID-19 vaccine that is available today helps protect against infection by the omicron variant XBB and its subvariant XBB.1.5 that dominate infections today. The present bivalent booster was made specifically against both the initial SARS-CoV-2 virus and the BA.4/BA.5 variants. However, BA.5 and its subvariants account for just about two percent of cases now, and BA.4 and the original virus are essentially gone. The present bivalent booster is effective, even though it was not made from the viruses circulating today. The more boosters you have received, the higher the protection against infection.
• More than 55 million North Americans (20 percent) have received the latest bivalent booster, compared to close to 270 million who have received at least one dose of the original vaccine.
• The bivalent booster has been shown to reduce mild COVID-19 disease infection by more than 50 percent, and it reduces the death risk 13 times that of being unvaccinated.
• Protection against COVID-19 fades within about three months against XBB, faster than against other variants.
• The present bivalent BA.4–BA.5 vaccine produces higher neutralizing responses against all the viruses found today. Those who have had both an infection and the vaccination had the highest recorded neutralizing antibody titers, and those who had only the vaccination has significant rises in antibody titers (NEJM. Jan 26, 2023). The highest antibody titers were at four weeks and started to drop after that. Hospitalization after severe infection 15 to 99 days after receiving the bivalent vaccine was 35 percent lower than in those receiving the monovalent vaccine.

As of January 9, 2023:

The Latest COVID-19 Mutation XBB.1.5:  The reason why COVID-19 is here to stay is because as soon as a person develops immunity by infection or vaccination to one strain of COVID-19, the virus mutates, so that your immunity doesn’t recognize that COVID-19 virus and has to learn how to attack and destroy a different form of the virus.  This newest virus mutation came from India in mid-August, 2022, and spread to Singapore and other parts of Asia.  One month ago, XBB.1.5 caused only one percent of COVID cases in the U.S.  Two weeks ago, it caused 22 percent of infections and last week, it caused 41 percent of COVID cases in the U.S.  The new XBB.1.5 mutation is now the most common cause of infection in the U.S. and in the northeast U.S. now, it causes 75 percent of COVID-19 infections.  Reports from Singapore where XBB.1.5 is rampant show that it has not caused any increase in hospitalizations for COVID-19. This means that it is highly contagious, but does not appear to cause much severe disease.

As of December 25,  2022:

Heart Muscle Damage Can Occur After COVID-19 Vaccination:  A review of 23 observational studies of 854 people (ages 12-20) with myocarditis after COVID-19 vaccination, found that heart muscle damage after COVID-19 vaccination in adolescents and young adults occurs in 3-5 people per million vaccinated (JAMA Pediatr, Dec 5, 2022):
• Only four percent had had a prior COVID-19 infection
• None of the patients had prior heart disease
• Myocarditis occurred after the second dose in 74 percent of those cases
• Onset of heart symptoms occurred 2.6 days after vaccination
• Symptoms included chest pain, fever, headache, and difficulty breathing
• The troponin blood test level, suggesting heart muscle damage, was elevated in 85 percent
• The electrocardiogram was abnormal and commonly showed ST-segment changes (53%) and occasionally T-wave changes (15 percent)
• Only 15 percent showed left ventricular systolic dysfunction, with only one percent having severe dysfunction, and no patients who required mechanical support during hospitalization
• Only five percent had a pericardial effusion, excess fluid around the heart signifying heart damage
• The cardiac magnetic resonance imaging showed late gadolinium enhancement in 87 percent of patients.  This test shows heart muscle damage not caused by blocked blood flow.
• Myocardial edema (muscle damage) was seen in 58 percent
• The vast majority were hospitalized (92 percent), for an average of 2.8 days, and a quarter were admitted to the ICU
• Only one percent needed machine support of their heartbeats
• No deaths were reported.
• Other studies show improvements in ejection fraction, a stronger heart muscle, at three months (Lancet, Child and Adol Health, Nov 1, 2022;6(1):788-798).

Exercise Helps to Prevent Hospitalization and Death from COVID-19: A study of almost 200,000 adults in Southern California found that those who exercised for as little as 11 minutes a week were far less likely to be hospitalized from COVID-19 than those who did not exercise (Amer J of Prevent, Med. Dec 14, 2022). Those who exercised at least 30 minutes most days were four times more likely to survive COVID-19 than those who do not exercise That same group had reported earlier that, of more than 48,000 patients at the Kaiser Permanente health care system in Southern California, those who almost never exercised were at much higher risk of severe outcomes from COVID-19, including death, than patients of the same age who were quite active (Br J Sports Med, Apr 13, 2021;55:1099–1105). A review of many studies shows that exercise helps reduce the severity of many chronic diseases and infections (Compr Physiol, Apr, 2012;2(2):1143–1211).

Reinfection Rates from COVID-19 are High: The relative protection of prior infection against reinfection with the later Omicron variant is 56 percent, compared with 92 percent for the earlier Delta variant (N Engl J Med, 2022;386(13):1288-1290).  A study from Iceland found that the proportion of persons who become re-infected with COVID-19 at 18 months during the Omicron wave was 11.5 percent and the same for both one or two boosters. Reinfection rate was highest, at 15.1 percent, among those aged 18 to 29 years. Fewer reinfections occurred among older individuals (JAMA Intern Med, 2022;182(2):179-184).
• Longer time from initial infection was associated with a higher probability of reinfection.
• The results suggest that reinfection is more common than previously thought.

As of November 17, 2022:

Reaction to a COVID Vaccination May Mean Better Protection: Almost all healthy people will develop an antibody response to a COVID-19 vaccine or booster, which offers significant protection against the disease. Research studies are showing that people who develop adverse reactions after they receive a vaccination for COVID-19 have higher protective antibodies against COVID-19. This suggests that having an adverse reaction to the vaccine means that your immune system is responding to help protect you from a future infection. Reactions include fever, chills, muscle pain, nausea, vomiting, headache, fatigue, or injection site pain or rash.

• A study of 954 healthcare workers at Johns Hopkins found that those who had fatigue, fever, and chills after two doses of either the Pfizer or Moderna COVID-19 vaccines had a five percent higher anti-spike IgG antibody level (JAMA Intern Med, Aug 2021;181(12):1660-1662). These antibodies specifically help to prevent the COVID virus from entering human cells. Further good news was that almost all people who received the immunizations were protected by these same antibodies. The only exception was one person taking immunosuppressant drugs.

• A report on 928 people from the Framingham Heart Study, average age 65, after receiving two doses of either the Pfizer or Moderna COVID vaccine, showed that nearly all subjects made anti-spike antibodies. Those who had reactions to the vaccine had a 50 percent higher antibody response: 48 percent reported systemic symptoms, 12 percent reported local symptoms only, and 40 percent reported no symptoms (JAMA Netw Open, 2022;5(10):e2237908).

• A German study found that men, but not women, with more severe adverse reactions to vaccinations had a 150 percent higher median SARS-CoV-2 RBD IgG titer compared to those with no reaction (Vaccines, Sept 27, 2021; 9(10):1089).

• Another study found that those who had a severe reaction to the vaccine had slightly higher antibody titers (Vaccines (Basel), Sept 24, 2021;9(10):1063).

• A study of South Korean healthcare workers was one exception. The authors found that all people who received the COVID-19 vaccine developed high antibody titers, but the study did not find higher anti-spike IgG antibody levels in those who had reactions to the AstraZeneca or Pfizer vaccines (Korean J Intern Med, 2021;36(6):1486-1491).

My Recommendations
The Moderna and Pfizer vaccines are highly effective in producing anti-spike antibody titers that help to protect you from infection by COVID-19. However, some people who have defective immune systems or are taking immune suppression drugs may not produce adequate protective antibodies. People who develop a reaction to the vaccine produce higher levels of protective antibodies. Reactions include a site rash or sore, swollen arm, fever, chills, muscle pain, nausea, vomiting, headache, or fatigue For most people, protective antibody titers start to drop a month after vaccination, so repeat vaccinations or boosters may be needed.

As of October 7, 2022:

Reasons to Get the New Bivalent Vaccines for COVID-19:  Everyone should consider getting the new bivalent COVID-19 vaccines that contain both the old and new COVID-19 viruses. The previous vaccines do not prevent most infections now because:
• They did not contain Omicron BA.5 subvariant, the dominant mutation of COVID-19 infections worldwide today.
• Your immune system has not seen this present Omicron BA.5 subvariant in any previous vaccine or previous infection with COVID-19.
• The immune boosting effect of vaccines may last for only a month or more (N Engl J Med, 2022; 387: 21-34.2).
• Historically, those who are immunized and also have had the COVID-19 infection have the best protection from future infections, although the protection is not complete (Lancet Infect Dis, Sept 21, 2022). We do not have data on the new bivalent vaccines yet, but there is an extremely low incidence of hospitalization or death up to 24 weeks after any of the previous COVID-19 vaccines (JAMA, September 26, 2022).

As of July 28, 2022:

First Conventional COVID-19 Vaccine Is Approved for Ages 18-Up:  The U.S. Food and Drug administration and CDC have authorized the Novavax vaccine as the first conventional COVID-19 vaccine (New York Times, July 20, 2022). The U.S. government has purchased 3.2 million doses of the vaccine so far.

The newly-approved Novavax vaccine uses the same type of technology that was used in the U.S. for previous vaccines such as flu, whooping cough, hepatitis B and shingles. It combines harmless proteins from the COVID-19 virus with an adjuvant that augments a person’s immunity to fight off the virus. Studies in the U.S., Britain and Mexico have reported that the Novovax vaccine produces protective antibodies against the Omicron-BA.5 virus, the most-common COVID-19 virus in the U.S. today.

The previous Moderna and Pfizer vaccines are messenger RNA vaccines based on an entirely new technology developed since the start of the current COVID-19 pandemic. Almost 80 percent of U.S. adults have received two injections of the messenger RNA vaccines and 51 percent have received one or more booster doses. However, 26 to 37 million adults have not received a single dose of these messenger RNA vaccines.

So far, research has shown that the messenger RNA vaccines appear to be safe, but there is a minority of people who feel that we have not waited long enough to find out if there is any long-term harm from the messenger RNA vaccines. Hopefully, the new Novavax vaccine will encourage these people to be vaccinated.

As of June 25, 2022:

Vaccines Reduce COVID-19 Deaths: A study of the death records from 185 countries found that nearly two-thirds of the world’s population has had at least one COVID-19 vaccine, and it has prevented nearly 20 million deaths worldwide (The Lancet Infectious Diseases, June 23, 2022). More than 3.5 million COVID deaths have been reported since the first vaccines were administered in December 2020.

A Previous Infection May Not Protect You from Suffering a New Infection with the Most Recent Mutations of COVID-19: The COVID-19 virus keeps mutating to change its structure so that even if you are vaccinated with boosters and have had a previous infection, you may not be protected from being infected with a newly-mutated COVID-19 virus (Nature, June 17, 2022). The good news is that your partial protection from previous exposure to COVID-19 makes it more likely that if you are re-infected, you will have a mild case. The newest mutations called BA.1 – BA.5 are less likely to cause protracted COVID-19 infections, called long COVID, than the earlier viruses (Lancet, June 18, 2022).

Moderna’s New Vaccine: Moderna just released new study results showing a fivefold increase in neutralizing antibodies for its new booster that contains the original mRNA-1273 (Spikevax) vaccine and one specifically designed to target the more recent BA.4 and BA.5 Omicron subvariants that now account for more than 35 percent of U.S. cases.

How Your Immune System Works to Protect You: When you have an infection or are vaccinated against a certain virus, your immune system makes proteins called antibodies that attach to and kill the invading germs. However, after an infection or vaccination, the antibodies in your bloodstream drop to extremely low levels. You have immune memory T-cells that can remain and when you are exposed again to that virus, these memory T-cells recognize the invading germ by its surface proteins and cause your body to make new antibodies specifically against that invading germ, to help protect you from suffering a new infection.

Viruses Mutate: Viruses continuously mutate or change their surface proteins so that your immunen system may not recognize them and you can be infected again. The COVID-19 virus has already undergone many mutations. There was the Delta COVID-19 virus that mutated into the Omicron virus, so that people who had been infected with Delta were susceptible to being infected with Omicron within weeks of recovering from Delta. However, they were more likely to have at least partial immunity from their previous infection so that they had mild disease.

The COVID-19 Viruses Today: The most recent COVID-19 viruses in the United States came from the Omicron strain and are called BA.1 that has mutated to BA.2, to BA.3. to BA4 and now BA.5. Most of the most recent cases are now BA.4 and BA.5. A person who has been infected with BA.2 can still become infected later with BA.5 but is more likely to have a mild case. As of today we have no data to predict whether a person who has been infected with BA.2 will be protected from developing an infection with BA.5.

New Circulating Viruses Less Likely to Cause Long COVID: The Omicron mutations that are causing new infection today are half as likely to cause long COVID syndrome as the previous Delta strains. The new strains cause 4.4 percent of cases to suffer long COVID syndrome, which is well below the nearly 11 percent associated with the earlier Delta variant. However, the new variants are more contagious. Long COVID syndrome can include symptoms that last for weeks, months or years: fatigue, fever, malaise, trouble breathing, cough, chest pain, heart palpitations, dizziness, diarrhea, stomach pain, muscle ache, rash, irregular periods, foggy thinking, depression, anxiety, headaches, protracted sleep, and loss of smell and taste.

As of May 14, 2022:

Another Study Shows Second Booster Effective in Preventing Serious COVID-19:  I think that most people should get the second booster dose (their fourth-dose of COVID-19 mRNA vaccination) because it is well tolerated and increases protection from serious disease by raising both cell and antibody immunity (Lancet Infectious Diseases, May 9, 2022). A randomized trial of 166 men and women, average age 70, who received their second booster dose of COVID-19 vaccination seven months after the first booster dose, showed a significant rise in anti-spike protein immunoglobulin (Ig)G titres and cellular responses measured 14 days after the injection.  The most effective laboratory tests to tell if you are protected from COVID-19 measure anti-spike protein antibodies and white blood cells that kill the virus. There was a significant drop in the anti-spike protein antibody approximately seven months after the first booster dose and before the second booster dose was given. The cellular (T-cell) responses were also raised considerably two weeks after the second booster dose. Pain and fatigue were the most common side effects, but no serious side effects were reported in this study. The authors think that antibody titers will drop as they did after the first booster injection, so it is likely that an additional booster injection will be recommended, probably a year after the second booster injection.

As of April 17, 2022:

Second “Booster Dose” Helps to Protect People over 60: After two initial Pfizer vaccine doses and one booster dose, a study showed that 182,122 adults ages 60 and over who received a second booster dose gained 52 percent protection against asymptomatic infection and 76 percent protection against COVID-related death 14 to 30 days after the booster was given (N Engl J Med, April 13, 2022). Protection against harm from COVID-19 increased as days after vaccination increased. The highest protection occurred at days 14 to 30 after receiving the second booster dose.

Boosters Reduce Hospitalization: The COVID-19 mRNA vaccines’ two-dose primary series appeared to provide less protection against hospitalization from Omicron variant infections than Alpha and Delta infections (JAMA, April 12, 2022;327(14):1323). A booster dose, however, was associated with increased effectiveness against Omicron hospitalizations at the same high levels achieved against earlier variants with two doses. The study included data from 11,690 adults admitted to 21 U.S. hospitals from March 11, 2021, to January 14, 2022. The two doses of vaccine increased prevention of hospitalization by 85 percent during Alpha and Delta infections, but only 65 percent during Omicron infections. Adding a third booster dose increased prevention of hospitalization to 86 percent. Vaccines reduced all types of COVID-19 severity significantly (BMJ, Mar 9, 2022; 376: e069761).

Most Reactions to COVID-19 Vaccine are Mild: The CDC reports that during the first six months of the U.S. COVID-19 vaccination program, most adverse events were mild and short-lived (Lancet Infectious Diseases, March 7, 2022). Almost 300 million mRNA vaccine doses were administered in the U.S. between December 14, 2020, and June 14, 2021 (JAMA, April 12, 2022;327(14):1323). Of the 340,522 reports of vaccine side effects, 92.1 percent were classified as non-serious; 6.6 percent as serious but not resulting in death; and 1.3 percent were deaths. The most common serious reports were shortness of breath, fever, fatigue, and headache. The most common cause of death was heart disease. The less serious reactions were more common after the second dose, compared to the first dose.

COVID-19 Vaccination Reduces Infectious Viral Load: Usually the more virus in a person infected with COVID-19, the more serious the disease. Viral load was measured in 600 infected symptomatic patients (Nature Medicine, April 14, 2022). The Delta variant caused a higher viral load than the original virus or the Omicron variant. Vaccination dramatically reduced viral load for Delta and Omicron infections, but a booster dose was necessary for the Omicron infections. Omicron’s very high infectiousness is caused by factors other than viral load alone.

As of April 10, 2022:

Who Should Get a Second COVID-19 Booster?  On Tuesday, March 29, 2022, the U.S. Food and Drug Administration authorized a second booster dose of the mRNA vaccines made by Pfizer or Moderna for all adults 50 years and older, to be given at least four months after the first booster of any approved COVID-19 vaccine. At this time, scientists do not have enough data to show that most people need to get this second booster dose. The primary concern is the highly contagious Omicron subvariant known as BA.2, which is now the dominant version of the virus in new U.S. cases (New York Times, March 29, 2022). The research data so far show that a fourth injection offers additional protection for people over 6o and those with conditions that impair their immune systems.

A study from Israel posted online this week, but not yet reviewed or published, reports that adults over 60 years of age who received a fourth injection were 78 percent less likely to die of COVID-19 than those who got only three injections. However, other studies show that a second booster has very limited benefits for healthy people under sixty and that a fourth dose did not raise antibody titers higher than it did after a third dose. Again, the person who is at high risk for serious disease is older or has a condition that can impair his immune system.

Who may need an mRNA booster now?
• a fourth injection for those who have received three doses of an mRNA vaccine from Moderna or Pfizer, and are over 60 or have an impaired immune system
• a third injection for those who received one dose of the Johnson & Johnson vaccine and a booster shot of an mRNA vaccine
• a third injection for those who received two doses of the Johnson & Johnson vaccine

Most likely, people who have had COVID-19 do not need a fourth injection because the highest and most effective immunity usually comes from having the disease, rather than from receiving the vaccine.

Older entries can be found in the post titled Latest on COVID-19: Archive