COVID Transmissions for 1-19-2022

Vaccination vs long COVID; tests in the US; avoiding the unavoidable COVID-19

Jan 19, 2022

Greetings from an undisclosed location in my apartment. Welcome to COVID Transmissions.

It has been 764 days since the first documented human case of COVID-19. In 764, the 6th Doge of Venice was deposed after refusing to make requested donations to the Pope. Over an extended period including this particular year, Venice starts to become a wealthy and important city-state with a large trading network.

Speaking of small countries, today we’re going to talk about an Israeli study looking at the effects of vaccination on Long COVID, discuss a US home test distribution system, and also we’ll talk about why (in my opinion) you should avoid COVID-19 as long as possible, even if you can’t avoid it forever.

It’s nice to be back after a very brief break.

Bolded terms are linked to the running newsletter glossary.

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Now, let’s talk COVID.

Israeli study of Long COVID and vaccination

In Israel, there is some interesting work going on regarding Long COVID/PACS1. Specifically, researchers there have looked at vaccinated, unvaccinated, and even uninfected populations, and come to an impressive—if true—finding: people who have been vaccinated for COVID-19 who get COVID-19 have the same rate of Long COVID symptoms as people who were never infected at all.

The meaning of this observation is that vaccination reduces the rate of reports of Long COVID symptoms down to the baseline, coincidental rates of these symptoms that are observed without getting COVID-19 at all.

Here is the key figure from their work:

The image shows a bar graph listing frequencies of various long-term PACS symptoms in four groups: uninfected people (royal blue), people vaccinated with 2 doses (lavender/purple), people vaccinated with 1 dose (green), people who are unvaccinated (periwinkle blue). For all symptoms, people vaccinated with 2 doses have similar symptom rates to people who were not infected at all, while the unvaccinated and people with only one dose of vaccine have much higher rates of these symptoms. The full symptom list is, left to right arranged by overall decreasing frequency: fatigue, headache, weakness of limbs, muscle pain, loss of concentration, hair loss, insomnia, dizziness, persistent cough, shortness of breath. PS to the authors of this paper: thanks for using a color palette where the colors were so easy to describe in text (sarcasm).

These results are really encouraging, but they are not without their limitations. These were collected by participants filling out an online form, and so because the symptoms are all self-reported, there may be some issues with that. The uninfected group’s data was collected incidentally, and the patient groups are not matched to each other. This study has been revised after being posted as a preprint; the authors took to heart discussions of their results on Twitter and improved their work—pretty cool to see that! But it’s still a preprint, and hasn’t been peer-reviewed. You can find it here: https://www.medrxiv.org/content/10.1101/2022.01.05.22268800v2

I wouldn’t call this the definitive study of Long COVID/PACS symptoms, but there have been other papers that likewise suggest a protective effect of vaccines against these symptoms.

On the other hand there have also been studies where the protection is unclear. Still, I am taking this as an encouraging sign. We still do not know a lot about long-term symptoms of this disease. I am hoping that as we do learn more, that knowledge will work considerably to our advantage in preventing and treating these effects.

US launches mailed testing program

The much-anticipated program where the US Postal Service will mail 4 rapid COVID-19 tests to any American household that requests them is now available on the postal service website: https://special.usps.com/testkits

I don’t really think that 4 tests per household are going to make a huge impact on society, but you know, if they prevent some infections, good. What I am hoping is that the intense popularity of the program will encourage the government to expand it. Please, go and request some tests if you’re in the US. I’ve ordered some, because there is a person in my household who has still not had COVID-19, and if needed, these tests will be used by people who come to visit us in order to protect that young person.

There are many ways these can be useful to US citizens, as many countries around the world have been able to demonstrate.

Even if these only detect 10% of contagious cases (and they can detect far more than that!), keeping those cases out of circulation has real, tangible effects downstream. Because viruses spread exponentially, preventing 1 case tomorrow could mean by next month you’ve stopped a transmission chain with thousands of cases in it.

Opinion: “We’re all going to get it sooner or later”

I’ve been having a lot of conversations about the idea that getting COVID-19 is inevitable, and I don’t think I’ve seen a COVID-19 message be as broadly misunderstood as this one.

Let’s unpack it a bit. I want to start not with the overall message, but with “get it.” What does it mean to “get it” in the context of COVID-19?

Well, eventually, everyone is going to get exposed to SARS-CoV-2. There are a number of options for what an exposure can lead to, in the short term:

No infection (more likely if you are vaccinated; if you are unvaccinated the “no infection” scenario probably means you remain vulnerable)
Asymptomatic infection (more likely if you are vaccinated; likely yields meaningful immune response)
Symptomatic infection that does not require medical attention (also more likely if you are vaccinated; likely yields meaningful immune response)
Serious symptomatic infection, requiring hospitalization (substantially less likely if you are vaccinated; can lead to long-term injuries, some of which may be permanent)
Death (substantially less likely if you are vaccinated)

In the long term, it’s still somewhat unclear what the relative risks here are for Long COVID/PACS, and it does not seem to track with what you experience from the above, but I am at least hopeful (based on data like what I shared today) that vaccination will help on some level to prevent that particular outcome.

Among the options in the short term on that list, 3, 4, and 5 are definitively COVID-19. 1 and 2 are encounters with SARS-CoV-2 but are not necessarily COVID-19. All of these, however, are within the possibility space for events that I think will eventually happen to all of us.

The reason that I think these will eventually happen to us all is that SARS-CoV-2 is not going to go away any time soon. It is widespread among people, and it is also present in a pretty substantial amount of human-adjacent animals. Even if we could eliminate this highly prevalent disease from humans, we are not going to be able to vaccinate and mask all the wild deer in whom it is circulating. This virus will be with the human species for a long time, longer than matters for anyone reading this as one of my contemporaries.2

However, just because we are all going to experience one of the above situations does not mean that we need to go out and make it happen now. If we all do this together at the same time, it’s going to cause big problems as we overload the systems that exist to prevent (5) from happening frequently. That was the big risk back in 2020 when this first emerged, and since we had no other defenses besides wearing makeshift masks and closing down gatherings and businesses, we used those options.

We’ve learned more now, and we have vaccination that reduces the risk of outcomes (4) and (5) by eye-popping amounts. The more people are vaccinated in a geographic area, the less likely it is for its systems to become overwhelmed. We also have better masks and rapid tests, both of which can help people who are in conditions (2) and (3) isolate themselves and reduce contagion. Masks can also help people reduce their chances of any exposure at all, and thus delay reaching any of these outcomes. We also have antivirals that are currently quite effective at preventing high-risk people in category (3) from entering (4) or (5).

In other words, we now have tools that make life with COVID-19 a lot more livable and allow us to navigate a situation of exposure. But, we still shouldn’t all get COVID-19 at once. It is still very possible for it to cause disruption to society and individual harms.

As we continue to navigate the emergence of this disease, technologies are going to continue to improve, also. The best time to get COVID-19 is LATER. As much later as possible. While it is possible still that some future variant might cause worse disease, so far that has not been the trend. Variants that have emerged so far have had mutations that expand their pool of susceptible hosts or that make them more effective at disseminating themselves. Pathogenicity factors do not appear to have changed, and there have been plenty of infections where it has been possible for the virus to mutate genes involved in pathogenicity. Under the current evolutionary pressures, it hasn’t been advantageous for these mutations to survive. So I really do think that as we go into the future, we are going to get better at fighting this virus than it is going to get at killing us.

That means you want to delay getting this as long as possible; on the other hand, I just don’t think it’s possible to avoid getting it forever. Right now, every day, you have a fixed chance of getting COVID-19. The only way for this to be 0 is for you to live alone as a hermit and never leave your home or have anyone visit you at it. For any event where a non-zero risk is repeated over time, as time goes on, it’s bound to happen.

Of course, you could make it so that this guaranteed occurrence only happens if you live for another 200 years, but again, this would require pretty extreme measures. Instead, it is more likely that your chances of a COVID-19 event start to get to 100% after between 5 and 50 years rather than hundreds of years. So, we should all prepare for an eventual encounter with this virus.

There are many events in life that we cannot avoid; growing up. Death. Tax day. However, we don’t try to hasten these events. No one should try to hasten getting COVID-19 either.

The reason that I emphasize the inevitability of this is not to frighten, demoralize, or dishearten. It is also definitely not to encourage you to give up. You don’t want to go out and get COVID-19 any more than you want to go out and get Salmonella food poisoning, but you’re more used to the latter and thus probably not quite as scared of it.

Instead the reason that I’m saying this is that I want to set reasonable expectations. I have seen people who are still promising that a zero COVID model is possible and that it can lead to eradication. This is a false promise and I do not want anyone to be misled. SARS-CoV-2 is a coronavirus present in the human population and it is not going away.

It is also not an endemic, minimal-thread virus like the human coronaviruses. It still causes massive waves of infection and large numbers of bad outcomes.

What I want to suggest is that, framing the problem as I have here, you try to navigate the post-emergence world in a way that allows you to control your battle with COVID-19 as much as possible. This means taking reasonable precautions like masking when around other people in areas of meaningful transmission. It means using rapid testing to decide whether or not to see friends. It means, for certain, getting vaccinated—as well as boosted if that is an option for you.

All of these things allow you to increase the odds that your encounter with SARS-CoV-2 will come at a time of your choosing: later. You can’t choose the exact time, but you can work hard to make it come long after you have prepared the battlefield by vaccinating yourself, encouraging a healthcare system that is ready to receive you, and giving the scientific apparatus of society time to discover even better ways of ensuring you experience the best outcomes.

It may be unavoidable over your whole lifetime, but for certain, this experience is one that I strongly recommend you delay as long as reasonably possible.

What am I doing to cope with the pandemic? This:

Readying for a major presentation

Next week, I’m presenting at the National Meeting for my company’s medical team. At work I am in charge of internal and external medical and scientific education programs, and I’ll be talking about what we will do in 2022. It’s exciting to tell my colleagues in our medical field force what I have planned for their educational calendar in the coming year.

Comments on the last issue centered on questions about an Omicron-specific vaccine. I don’t feel comfortable making definitive statements about that at this time, so if you’d like to read those, go back to that issue to find them.

You might have some questions or comments! Join the conversation, and what you say will impact what I talk about in the next issue. You can also email me if you have a comment that you don’t want to share with the whole group.

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