It’s time to get out your masks and air filters if you haven’t already. We are in a COVID wave that is as big or bigger than last winter’s wave in some places. The main variant causing COVID infections now is KP.3 (JN.1 + FLuQE) and its descendant KP.3.1.1 is trying to push it out. KP.3.1.1 has the addition of the S31deletion mutation which makes it more infectious and better able to evade antibody neutralization. Other subvariants with the same S:S31del mutation (e.g., KP.2.3 and LB.1) also have higher immune evasion compared to those without (e.g., JN.1, KP.2, and KP.3) and we are seeing the S31del mutations increasing COVID infections in different places.
COVID wastewater levels are “HIGH” nationally now per the CDC. The West Coast is particularly high. Emergency department visits are up across the United States for acute COVID infections, especially in some of the larger states like California, Texas and Florida. Between June 30 and July 12, WastewaterSCAN reported a 54% increase in SARS-CoV-2 virus levels, showing HIGH viral levels in most regions across the U.S. and MEDIUM in the Midwest.
From: https://www.cdc.gov/nwss/rv/COVID19-nationaltrend.html
Sara Anne Willette’s analysis shows that SARS-CoV-2 wastewater levels are EXCESSIVE (HIGHEST) in Oregon, Utah, Florida, and Connecticut. They are VERY HIGH in Washington state, Nevada, Wyoming, New Mexico, Maryland, and New Hampshire, followed by HIGH levels in California, Idaho, Colorado, Texas, Louisiana, N. Carolina, W. Virginia, Minnesota, Vermont.
SARS2 Wastewater from Sara Anne Willette https://iowacovid19tracker.org/
Some of the highest levels of SARS-2 virus in wastewater this week according to WastewaterSCAN are in E Orange Co FL 3096 PMMoV, SW St Petersburg FL 2879 PMMoV, Little River Roswell GA 2847 PMMoV, W Bank New Orleans LA 2744 PMMoV, SW Orange Co FL 2648 PMMoV, Anchorage AK 2248 PMMoV, and Portland ME 1966 PMMoV. Here in the Bay Area, recent COVID levels in San Jose, Sunnyvale, Oceanside San Francisco and SE San Francisco have been higher than during in our winter wave.
According to JP Weiland, currently in the United States, there are 780,000 new infections each day and on a national level 1 in every 43 people is currently infected with COVID. However, in the West 1 in every 25 people is infected, in the South 1 in 34 people is infected, 1 in 59 in the Midwest and 1 in 73 infected in the Northeastern U.S. He expects that we will hit the peak of this COVID wave in the next few weeks. Although hospitalizations and deaths are lower than they were in the beginning of the pandemic, many people will continue to get Long COVID and other long term consequences of COVID infections such as increased risks of heart attacks, strokes and increased new onset diabetes.
From JP Weiland: https://twitter.com/JPWeiland/status/1814382044757024943/photo/1
As you most likely know, President Joe Biden has COVID now and so does Second Gentleman Douglas Emhoff, as does the mayor of Los Angeles. It has been a long time since most people have been vaccinated against COVID and the XBB.1.5 COVID vaccine from last fall does not protect against new variants like KP.3 that are circulating now. The updated KP.2 mRNA vaccines are expected to come out in the next month or two.
COVID cases have surged every summer since the pandemic began. Experts say this is due to more people traveling, large events like weddings and conferences, new variants of the virus, and people staying indoors because of the heat. It is very important to wear an N95 mask or KN95 mask on airplanes, especially while the plane is boarding and before it is in the air when the air filtration system turns on. Longer flights increase the risk of getting a COVID infection- for every 1 hour increase in flight length, there is a 53% increase in risk of getting infected. I’ve included links to wastewater SARS-2 levels in other countries that are still reporting in my “COVID notes” below.
Paxlovid still works against the latest variants, although it may be hard to get if you are traveling. Therefore, you may want to get Paxlovid before you leave on vacation in case you get a COVID infection on your trip. You can find which pharmacies have it in stock here. Remember to check to make sure that you do not have to stop any of your other medications while taking Paxlovid using the University of Liverpool drug checker here. The Pfizer PAXCESS program will reimburse your co-pay if you have insurance or may pay for the Paxlovid prescription if you do not have insurance. Make sure to join the PAXCESS program before going to the pharmacy to pick up Paxlovid. Remember, COVID rebound is about the same for people who took Paxlovid and for those who did not. The risk of rebound has more to do with the person’s immune system response and not the medication taken.
Some people are choosing to take Metformin if they get a COVID infection, as it has antiviral properties and can reduce the risk of Long COVID as well. The dosage used in the randomized trial that showed Metformin to be effective against acute COVID infections was titrated over 6 days: 500 mg on day 1, 500 mg twice daily on days 2–5, then 500 mg in the morning and 1000 mg in the evening up to day 14.
The Tour de France has reinstated protective measures like mask mandates requiring race organizers, media, and guests to wear masks when in contact with riders and team staff. Riders Tom Pidcock, Juan Ayuso, Alexey Lutsenko and Michael Morokov all have COVID now and have dropped out of the Tour. Geraint Thomas is also infected with COVID but is continuing to race. The Paris Olympics start next week and will bring many athletes and spectators from around the world.
In a target emulation trial from Hong Kong using the EHR records of patients hospitalized for COVID, those treated with Paxlovid (nirmatrelvir-ritonavir) alone were calculated to have a lower risk of mortality, ICU admission, or the need for ventilatory support compared to those treated with Paxlovid and Remdesivir combination therapy or Remdesivir alone. Randomized controlled trials are needed to confirm these findings.
A new study from Scandinavia of 343,066 liveborn infants confirms that there is no increased risk of birth defects from COVID vaccination or COVID infection in the first trimester.
Long COVID
Ziyad Al-Aly and colleagues put out a new study this week showing that with the original virus in 2020, 10.3% of people got Long COVID in their Veterans Administration population. With Delta, 9.5% of unvaccinated people got Long COVID and 7.7% of unvaccinated individuals got Long COVID during the Omicron era. For vaccinated people, the rate of long COVID during Delta was 5.3% and 3.5% during Omicron. Fortunately, vaccination has helped decrease the amount of people getting Long COVID. Despite a decrease in the percentage of Long COVID cases however, many people continue to be infected with COVID which means that cumulatively many people continue to fall victim to this disabling disease.
We are presently in a COVID wave with 780,000 new infections each day. If all of those people are vaccinated, we would expect that about 27,300 would get Long COVID each day (780,000 x 3.5%). That means that about 800,000 people will end up with Long COVID this month alone. It continues to be important to try to avoid getting reinfected with COVID.
Toll on Disability-Adjusted Life Years (DALYs) shown in the graph below. Vaccination significantly reduced the risk of Long COVID. From: https://www.nejm.org/doi/full/10.1056/NEJMoa2403211
A new paper from Vienna shows that even mild COVID infections lead to long term changes in the immune system in people who “recovered” from COVID infection and did not develop Long COVID. Researchers followed non-vaccinated people for at least 10 months. Those who got COVID infections had long term reduction of innate and adaptive immune cells with a shift from Th1 to Th2 serum cytokine profiles seen at 10 months. They had reduced absolute granulocyte, monocyte, and lymphocyte counts, involving T, B, and NK cells.
In a mouse model of Respiratory PASC (a Long COVID phenotype with mostly lung symptoms), giving anti–interferon-γ (anti–IFN-γ) treatment after the acute COVID infection stopped the mice from getting Respiratory PASC. The authors suggest that treatment with a similar anti-interferon-gamma medication may help people with Respiratory Long COVID.
Emily Mendenhall wrote a piece in the Lancet about Ryan Prior’s book The Long Haul: How Long Covid Survivors Are Revolutionizing Healthcare. Prior had post-viral ME/CFS since he was a teen after a mononucleosis (Epstein-Barr Virus) infection. He fortunately is in remission. In his book, he describes the activism of Long COVID patients Fiona Lowenstein, Elisa Perego, Hannah Davis, Lisa McCorkell, Gina Assaf, Hannah Wei, and Athena Akrami which included organizing online groups and generating the first database of Long COVID symptoms. His book also looks at the work of post-viral illness researchers Drs Michael VanElzakker, Amy Proal, Ziyad Al-Aly, David Putrino and Akiko Iwasaki.
H5N1
The July 19th update from the CDC on the H5N1avian flu states that “Since April 2024, 10 human cases of avian influenza A(H5) infection have been reported in the United States. Four of these cases were associated with exposure to sick dairy cows and six were associated with exposure to H5N1-infected poultry.” Human symptoms have been mild to date. The CDC also performed a seroprevalence study of 35 dairy workers in Michigan and found no H5N1 avian flu antibodies in their blood meaning that asymptomatic infections do not appear to be happening at least in this group.
Other news:
7/18/24 Bloomberg: Maternal Deaths Were Highest in States That Restrict Abortion https://buff.ly/4cFniV3
"Women were more than twice as likely to die in or around childbirth in some US states with severe abortion restrictions compared to those with greater access."
7/19/24 CDC: Listeria Outbreak Linked to Meats Sliced at Delis https://buff.ly/4cT4jq7
"Listeria is especially harmful to people who are pregnant, aged 65 or older, or with weakened immune systems. CDC always recommends people at higher risk for listeriosis avoid eating meats sliced at the deli or heat them to an internal temperature of 165°F or until steaming hot before eating."
7/19/24 STAT news: Microsoft global outage forces health systems to cancel appointments, delay procedures https://buff.ly/3Wx7372
An error in a Microsoft CrowdStrike update led to a widespread outage of health system computers and EHRs around the globe. The issue did not stem from a cyberattack.
7/15/24 Cell: Allogeneic CD19-targeted CAR-T therapy in patients with severe myositis and systemic sclerosis https://buff.ly/467tTFk
Off-the-shelf donor-derived CAR-T product targeting CD19 worked well in several patients to treat refractory autoimmune diseases.
7/8/24 Arthritis & Rheumatology: A genome‐wide association study suggests new susceptibility loci for Primary AntiPhospholipid Syndrome https://buff.ly/3YaYSOJ
“The comparison with other immune-mediated diseases revealed a close genetic relatedness to neuromyelitis optica, systemic sclerosis, and Sjögren's syndrome, suggesting colocalized causal variations close to STAT1-STAT4, TNPO3, and BLK.”
CNN: Boston Terrier Thor loves to swim. Watch Thor go bonkers with delight after his family builds him a pool in the garage.
Via AJ Willingham
Have a good rest of your weekend,
Ruth Ann Crystal MD
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