What I am doing about COVID-19 right now and why?

Three professors of Medicine comment on how they see COVID-19 in August of 2022.

The “19” attached to “COVID” indicates that the virus began in 2019. Two-plus years on, everyone is adapting in their own way.

We asked a few people in medicine to write about how they are behaving in terms of COVID-19 and what underlies those behaviors. We’ve held them to less than 750 words.

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First up is Andrew Davis, professor of Medicine, from the University of Chicago:

What do you foresee as the future of life with COVID? As of Dec 2021, 95% of adult U.S. blood donors had some degree of COVID-19 immunity from vaccination, prior infection, or a combination.

Pediatric seroprevalence in February 2022 was about 75%. Neither prior infection nor vaccination provide durable protection from hospitalization, particularly in the BA.5 era. As a consequence, we’re on track for 150,000 deaths from COVID-19 in 2022, weighted to those 65 and older or with comorbidities, and disproportionately affecting the poor, Black and Hispanic people, and red state rural residents. This makes COVID the 4th or 5th leading cause of death in the U.S., 5x the average annual toll of influenza.

What is your take on long COVID? While reinfections tend to be milder, VA data suggest worse outcomes with reinfection. Compared to those with first infection, those with reinfection exhibited a statistically significantly increased risk of all-cause mortality, hospitalizations, lung, cardiac, blood, kidney, neurologic, and mental disorders as well as diabetes and fatigue.

Long COVID itself is an evolving clinical and research field, significant following perhaps 5-15% of recognized infections. A key recent study in The Lancet captured symptoms in thousands of people before they were infected and followed them for months, with age and sex-matched controls who remained uninfected. 12.7% developed the condition based on persistent symptoms at 3-5 months in the Covid group, compared with 8.7% in the control group. Excess symptoms included chest pain, difficulties with breathing, painful muscles, general tiredness, and headaches. This is not surprising to clinicians who have seen lengthy post-viral syndromes throughout their careers. Recent research from Yale in pre-print form suggests machine learning components can identify Long COVID with over 94% accuracy, using 3 symptom complex clusters, Herpes (EBV, VZV) virus reactivation, and heightened immune system activation markers. These and other findings suggest HPA assessment may provide a useful biomarker. A useful Long COVID reference site comes from the American Academy of Physical Medicine and Rehabilitation.

How do you manage your risk around town (in shops, at restaurants, museums, concerts, public transport...) I shop, attend movies, theater, museums, and selected concerts without much concern, but mask when doing so with a good KN95, and try to pick quieter times and days of the week. For now, I dine outdoors at restaurants, and exercise outdoors maskless without worry. When family and friends visit, we generally sit apart in the room. When my daughter was married in June, the ceremony was outdoors. I pass on drinks and pretzels when I fly, and home test for cold symptoms.

How do you manage risk at work? I use NIOSH-approved KN95 consistently in clinical areas, add eye protection when evaluating respiratory symptoms, and eat in my office alone, or outdoors with friends. Every clinical visit is an opportunity to discuss boosting, analogous to how I discuss flu shots, and PrEP. Pregnant women are another important group for vaccination discussion. As of Aug 11, the CDC has removed a recommendation to quarantine, except in high-risk congregate settings (correctional facilities, homeless shelters, and nursing homes). In schools, (generally not considered high-risk congregate settings), people exposed to COVID-19 should follow recommendations to wear a well-fitting mask and get tested.

Final thoughts: Just as better highway and car design (and DUI laws) have reduced traffic fatalities, we need to engineer better passive protection to reduce COVID and respiratory illness in general. Class size, building ventilation and perhaps UV and HEPA air cleansing approaches deserve consideration. Masks have a role, and mask advisories, similar to seat belt laws, can be useful behavioral nudges. Kids aren’t supposed to die – peak pre-vaccine era annual deaths for childhood diseases like rubella, meningitis, and varicella ranged from 8 to 20. Yet for COVID in kids 6 months to 4 years (1/2020 – 5/2022) the figure was 86. And remember, other respiratory illnesses - annual pediatric flu deaths dropped from 170 on average 2018-2020, to 1 in the 2020-21 season. Lastly, get your COVID booster this fall!

Next up is Adam Cifu, another professor of Medicine from the University of Chicago

What do you foresee as the future of life with COVID? COVID will be with us forever. We will be getting sick with the descendants (future variants) of COVID much like we continue to deal with the descendants of the Spanish Flu. That fact makes me both angry and upset. I imagine an alternate reality in which we managed things differently from day-1 and avoided the terrible global impact of COVID. Although I am aware that 500 Americans continue to die of COVID daily and that there are dozens of people currently hospitalized at my medical center, I’m personally not that worried about COVID in August of 2022. This virus was so terrible in 2020 because we had no immunity. Now, most adult Americans (at least willing Americans) have been vaccinated. Many have some degree of immunity from a previous infection. Like all coronaviruses, this one will continue mutating and we will continue to be sickened, but as we gain and maintain immunity, it will be less and less likely that any single individual will become terribly ill. Thus, the idea that a new variant will set us back to March 2020 makes little sense to me.

What is your take on long COVID? People who get very ill from anything take time to recover. In addition, we (I) have seen patients with new syndromes after a COVID infection that we have to attribute to their infection. I think the incidence of this is small, far less than some of the published data have argued. I base this on my personal experience with hundreds of patients and peers who have had COVID.

How do you manage your risk around town (in shops, at restaurants, museums, concerts, public transport...)? I currently live much like I did before 2020. I, generally, do not wear a mask and there are no activities I avoid. What has changed for me is that I am more aware of infection risk and my ability to lessen that risk. If I have something important planned (a trip, a visit to an elderly relative), I will avoid the highest risk activities for 5 or so days before. Two weeks ago, before a week’s vacation, I passed on a dinner at a restaurant with a large group -- I didn’t want COVID to interfere with my travels. After some maskless flights, I am back putting on a surgical mask once on the plane. Far from perfect protection, not perfectly reasonable, probably unnecessary, but not troublesome for me.

How do you manage risk at work? Surgical masks are required at work. This is reasonable. At my medical center, we work in tight quarters and I see patient who are at high risk for complications of COVID. I wear an N-95 when I am with patients who I know, or suspect, have COVID. I am not sure when I will be allowed to unmask at work but when I am allowed I will.

Final thoughts: On the one hand, I look at COVID now as akin to other common upper respiratory infections. On the other, I am more careful about respiratory infections than I used to be. (I see this evolution as akin to our adoption of universal precautions during the worst of HIV). I am over 50 and I take a drug that affects my immunity. I am, of course, vaccinated. I’ll quarantine per guidelines when I have COVID and mask anytime I am ill (with other transmissible diseases) so as not to infect others. In the highest risk situations (e.g. on a train next to someone who is obviously ill), I’ll don an N-95 – why get sick if I can avoid it.

My current approach may seem cavalier -- I spend almost no time outside the hospital masked. It might also seem poorly reasoned if not idiotic -- “You walk through an airport unmasked and then wear a surgical mask on the plane?” My decision making is in line with the threat as I currently see it and my personal risk tolerance. I was extremely careful during those terrible weeks in the Spring of 2020 when I felt that I was at high risk and lapses in caution could threaten the lives of each of my contacts. I feel we are now in a very different place and few of us make completely rational decisions about everything.

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To close, the ever-rebellious Vinay Prasad deviates from the script. Who would have guessed?

What I am doing about COVID right now, and why? By Vinay Prasad

A disclaimer: this essay assumes I am not subject to rules or mandates. That’s largely true in my day-to-day life, but not in the hospital. I will discuss the hospital at the end.

What am I doing about COVID19? I am doing what any rational person should do: absolutely nothing. I’m living my life just as I lived in 2018. Here are the facts:

1. COVID is everywhere; it will never be eradicated; it will be intertwined with human beings for as long as our species exists.

2. COVID is highly contagious—particularly new variants—unless you plan on living in a bunker, and eating canned food for eternity, the question is not if you will get COVID, but when.

3. The next question is: When will you get it again, and again? Just like the 4 prior endemic coronaviruses, we will continue to be infected and reinfected in the years to come. That’s mother nature (or lab leak) for you!

4. The only thing we can do is to make sure we meet COVID with odds in our favor. For most that means lose weight, and get vaccinated (assuming you haven’t had COVID already).

I’ve done both those things. As much as I am willing. What am I doing now? I’m eating in restaurants like I did in 2018. I visit theaters and museums like 2018 (although, there haven’t been any good films). I will happily go to a nightclub or bar (you buying?). I am sure cloth masks don’t work; I do think a tightly fitted n95 works to delay infection, but you will never find me wearing one (outside of work) because it is pointless. I will get COVID anyway, and it is wretchedly uncomfortable.

If you are sick and coughing up a lung, I won’t hang out with you. This isn’t new to COVID19. I wouldn’t hang out you in 2018. Well, exceptions might be made (especially in college to spend time with a woman), but generally no. I’m not looking to get sick, but if I get sick in the course of life, then so be it. I worry avoiding all respiratory infections might be bad for us. We simply don’t know what it might do to autoimmunity or more. Human beings evolved for millions of years to have respiratory viruses from time to time; it is unnatural not to. We wrote about this in Unherd magazine.

If I visit you in your home, I will do things to make you comfortable (e.g. masking if requested). I am not rude. But I will never engage in virtue signaling, hypocritical posts like so many doctors who tweet about masks, then post selfies without them. Pathetic. The IFR for COVID19 was always debated. I won’t revisit 2020, but in 2022, it is clear the IFR for a 39 year old vaccinated man is on par with seasonal influenza. Rationally, I will do everything I did for seasonal flu in 2018, which isn’t much.

Long COVID doesn’t change a thing. First, what is it? The best study in the Annals of Internal Medicine performed dozens of laboratory tests for people suffering long covid and healthy controls and found absolutely no differences. It is always true that people who get very ill can take a long time to get back to normal, but, pre-covid, the idea you could have an asymptomatic respiratory virus and suffer long term damage was never documented, and would be viewed skeptically. Most importantly, long covid is a moot point. In so far as it is an issue, I will have to deal with in Sept 2022 or Nov 2022, when I get COVID. I can’t avoid it. In short, I am doing what nearly every single person in Switzerland is doing: living normally.

What about the hospital? The hospital is different. Like most MDs, I obey all rules and more to keep my patients safe. I don’t go to work when sick. I wear n95s in rooms with known COVID patients—that’s the rule. I know my n95 ‘works’ when worn perfectly for a short time, so it doesn’t matter if the patient wears a mask. If the hospital asks me to fill out that stupid daily questionnaire, I will. I follow all the thousand, random (mostly unproven) infection control rules, which have existed for years. I obey the speed limit.

If I really disagree with policy, I will litigate my case in op-eds and published literature. I did so before for TB testing. I won’t martyr myself, but will try to change the policy at the national level. Of course, that’s me. For my patients, I will always be their advocate. I will push to make exemptions to dubious visitor limit policies, when needed, and I don’t enforce rules that hurt patients.

Final thoughts: COVID19 has infected brain cells—just not the way most think. Many are irrationally anxious. COVID19 will infect us all (or ~93-97% of us) in short course. Have the strength to accept the things you can’t change, the courage to change the things you can, and the wisdom to know the difference. I do.