COVID news 2/4/23
COVID news 2/4/23
Hi all,
XBB.1.5 increased from 61% last week to 66% of U.S. cases this week, but overall hospitalizations and wastewater virus levels are falling despite XBB.1.5 being much more contagious and immune evasive. This is very good news. But, we still have to remember that there are more than 400 people dying each day of Covid across the United States and we cannot let our guard down.
President Biden announced this week that there will be an end to the Covid emergencies on May 11, 2023. This move will restructure the US response to Covid and will be accepting Covid as an endemic disease. There will be no more free vaccines or free home Covid tests, and millions of people will lose health insurance that was linked to the public health emergency. Flexibility for use of telemedicine will be extended at least another two years however.
This week there was a very interesting review in Nature about autonomic dysfunction and postural orthostatic tachycardia syndrome (POTS) in people with long Covid (PASC). I was surprised that 30% of people with long Covid have POTS syndrome. Manifestations of POTS in long Covid include local circulatory system symptoms from microvascular dysfunction including migraine, brain fog, chest pain, heat or cold intolerance and Raynaud-like symptoms. POTS also causes global circulatory symptoms including fatigue and exercise and tolerance, postural tachycardia and postprandial hypotension. A commentary in JAMA reviews this week on an article from December 2022, shows that people can get POTS after vaccination, although the risk of getting POTS after a Covid infection is at least five fold higher.
Regarding long Covid, a very interesting article from Germany shows that there is a 43% higher chance of getting a new autoimmune disease after a Covid infection. This includes a 55% of new onset Celiac's disease after Covid infection, a 42 to 40% increase in Rheumatoid Arthritis, a 25% higher risk of getting Type I Diabetes after a Covid infection and a 28% higher risk of Crohn’s disease. The highest risks for new onset autoimmune disease after a Covid infection were for autoimmune vasculitis syndromes, which include Immune Thrombocytopenic Purpura (ITP), Wegener’s, Temporal Arteritis, and Bechet disease. A different article showed that there may be increased auto antibodies to different nerves in the brain in some long Covid patients with cognitive dysfunction. This was a small study, and larger studies will be needed to confirm.
The FDA has now removed Covid testing requirements for high-risk people to get Paxlovid prescriptions. Previously patients could only get Paxlovid if they had a positive test but now “in rare instances, people with recent exposure and symptoms can be diagnosed with Covid even without the negative test result, and get Paxlovid prescribed.“ I have also included a link for health care providers to get 20 free boxes of Paxlovid from HHS HPOP for their clinical practices.
Regarding vaccination and good public health messaging, included is a photo of Elvis Presley getting a polio vaccination on national television in 1956. That one event was partially responsible for increasing immunization levels for teenagers in the US from 0.60% to 80% in just six months. Elvis Presley truly was the king.
Bharat Biotech reported promising data on the nasal Covid vaccine this week. The nasal vaccine against Covid was safe, well tolerated and elicited superior antibody levels and mucosal immune responses compared with two doses of the intramuscular Covaxin vaccine. Hopefully this nasal vaccine will be approved in the United States soon as it helps block the Covid virus from entering the body.
The CDC came out with data this week, showing that for all ages, the bivalent booster works to protect against hospitalization and death. A very interesting graphic graphical guide on the future of Covid vaccines was published in Nature this week. Future COVID vaccines need to include nasal vaccines for mucosal immunity to stop transmission and universal vaccines that are variant proof.
A pre-print from the University of Washington showed that a new home blood collection device using microneedle patches, called “Home RNA”, allowed researchers to follow changes in gene expression of immune factors during the course of a COVID infection. Over 418 dynamic genes associated with interferon and innate viral defense pathways were found to turn on and off over time. Unvaccinated patients had higher innate antiviral responses, interferon signaling and cytotoxic lymphocyte responses. In contrast, vaccinated people with breakthrough Covid infections showed lower interferon signaling and had enhanced early cell-mediated responses. Of note, IFI27, a key viral response gene, tracked very closely with the clearance of the SARS Covid virus longitudinally over time.
Other articles related to our immune response to COVID included a meta-analysis on hybrid immunity showing that when reinfected, people with hybrid immunity had a 97% lower risk of severe Covid infection at one year. And finally there was a detailed review article in the New England Journal of Medicine on the innate immune system and how it affects Covid.
There were several articles this week reminding us that animals can be reservoirs for the SARS-CoV-2 virus. Some white tailed deer still carry previous variants including Alpha, Delta and Gamma. A sick African lion transmitted Covid to several zoo employees. SARS-CoV-2 is known to infect a broad spectrum of animal hosts. A comprehensive article in Nature ISME Journal used cell culture to look at the susceptibility of 55 different mammals to SARS-CoV-2, SARS, and MERS-CoV. Thomas’s horseshoe bats, king horseshoe bats, green monkeys, and ferrets seemed like the most likely animal reservoir hosts for these three coronaviruses.
Have a good weekend,
Ruth Ann Crystal MD
Twitter: https://twitter.com/CatchTheBaby
Other news:
1/31/23 CNBC: Why the $7,500 EV tax credit may be tougher to get starting in March
IRS: Credits for New Clean Vehicles Purchased in 2023 or After https://buff.ly/3HpTf5e
1/31/23 AP: FDA moves to ease rules for blood donations from gay men
1/17/23 Becker's Hospital Review: 47% of physicians are 55 or older:
8 things to know about the physician workforce https://buff.ly/3Hx239r
COVID news:
https://medriva.com/charts/world-monitor.php
https://medriva.com/charts/usa-monitor.php
https://www.nytimes.com/interactive/2021/us/covid-cases.html
US cases:
US hospitalizations:
Walgreens positivity rate: https://www.walgreens.com/businesssolutions/covid-19-index.jsp
Variant tracker in US: https://covid.cdc.gov/covid-data-tracker/#variant-proportions
XBB.1.5 up to 66% from 61% last week.
Fortunately, despite XBB.1.5 being dominant in most US regions, hospitalizations and wastewater levels are not increasing.
Wastewater Monitoring:
CDC Wastewater Monitor https://covid.cdc.gov/covid-data-tracker/#wastewater-surveillance
Looking better
Biobot: https://biobot.io/data/
Sewer Coronavirus Alert Network (SCAN) project by Stanford University:
2/3/23 Paxlovid Order Request for Clinics https://buff.ly/3HwzuJs
20 free boxes of Paxlovid from HHS HPOP for clinical practices
2/2/23 Nature Reviews Cardiology: Autonomic dysfunction and postural orthostatic tachycardia syndrome (POTS) in post-acute COVID-19 syndrome (PASC, Long COVID) https://buff.ly/3JHiNO2
Cardiovascular autonomic dysfunction, with postural orthostatic tachycardia syndrome (POTS) is found in 30% of people with Long COVID. Prognosis is unknown, and treatment is still “unsatisfactory”.
Cardiovascular autonomic testing is needed to confirm a diagnosis of POTS.
The two main types of cardiovascular autonomic dysfunction — local and global — usually overlap.
Peripheral circulatory disorders are thought to stem from microvascular and endothelial dysfunction and can lead to local symptoms such as headache, cognitive impairment (‘brain fog’), chest pain (angina-like symptoms), dyspnoea, heat or cold intolerance, Raynaud-like phenomena and venous pooling.
1/25/23 JAMA letter: Large Cohort Study Finds Possible Association Between Postural Orthostatic Tachycardia Syndrome (POTS) and COVID-19 Vaccination but Far Stronger Link With SARS-CoV-2 Infection https://buff.ly/3XJSN90
Although it may be possible for some people to get POTS after vaccination, the risk of getting POTS after a COVID infection is at least 5x higher.
Study referenced from Dec 2022 https://buff.ly/3VRihjZ
This man spells out POTS with all of his empty medication bottles.
2/1/23 FDA: Paxlovid can be prescribed without a positive test in some cases.
2/1/23 Reuters: U.S. FDA removes COVID test requirements for Pfizer Paxlovid and Merck pills https://buff.ly/40nVcrz
Individuals with recent known exposure with signs and symptoms may be diagnosed by their healthcare providers with COVID even if they have a negative test result.
1/26/23 MedRxiV (Germany): Incident autoimmune diseases in association with a SARS-CoV-2 infection: A matched cohort study https://buff.ly/3j9GEuT
n = 641,704 patients with COVID infection
43% higher chance of getting a new autoimmune disease after COVID infection,
55% higher risk of developing new onset Celiac disease after COVID infection
41% higher risk of Grave’s disease
42-45% higher risk of Rheumatoid arthritis
25% higher risk of Type I Diabetes
27-29% higher risk of Crohn’s disease
The highest IRR was seen for autoimmune vasculitis (ITP, Wegener’s, Arteritis Temporalis, Behcet’s)
Patients with a more severe course of COVID-19 were at a greater risk for incident autoimmune diseases, but many with milder COVID also got new autoimmune diseases.
3/2023 Brain, Behavior, and Immunity: Association of cerebrospinal fluid brain-binding autoantibodies with cognitive impairment in post-COVID-19 syndrome https://buff.ly/3wOXfYg
In people with Long COVID (PASC) and cognitive impairment, abnormal Montreal Cognitive Assessment (MoCA) results were associated with the presence of anti-neuronal antibodies in CSF (p = 0.0004).
n = 50 Long COVID patients with brain fog
Anti-neuronal autoantibodies were found in 52 % of all patients: n = 9 in serum only, n = 3 in CSF only and n = 14 in both, including
autoantibodies against myelin, Yo, Ma2/Ta, GAD65 and NMDA receptor, but also a variety of undetermined epitopes on brain sections:
These included cerebral vessel endothelium, Purkinje neurons, granule cells, axon initial segments, astrocytic proteins and neuropil of basal ganglia or hippocampus as well as a formerly unknown perinuclear rim pattern.
1/31/22 Lancet Preprint: Immunogenicity and Tolerability of BBV154 (iNCOVACC®), an Intranasal SARS-CoV-2 Vaccine, Compared with Intramuscular Covaxin® in Healthy Adults: A Randomised, Open-Label, Phase 3 Clinical Trial https://buff.ly/3XUWJnh
Bharat Biotech nasal vaccine (BBV154, iNCOVACC®) made to generate mucosal immunity to prevent infection and human-to-human transmission.
Two intranasal doses of BBV154 were safe, well tolerated and elicited superior humoral (antibody) and mucosal immune responses compared with two intramuscular Covaxin injections.
Paxlovid
1/30/23 AP: President Biden to end COVID-19 emergencies on May 11 https://buff.ly/3HeLCyy
The move restructures the U.S. response to accepting COVID as an endemic threat.
No more free vaccines, free home COVID tests and many people may lose health insurance from Medicaid.
Telemedicine flexibilities will be extended another 2 years though.
The WHO said the coronavirus remains a global health emergency, but may be nearing an “inflexion point” where higher levels of immunity can lower virus-related deaths.
1/30/23 CDC COVID Data Tracker: Rates of COVID-19 Cases and Deaths by Vaccination Status https://buff.ly/3p5JqCa
Across all ages, the bivalent booster works.
12.7x lower death with bivalent booster compared to unvaccinated person.
2.4x lower death with bivalent booster compared to vaccinated people without the booster.
1/30/23 MedRxiV (UW): Longitudinal home self-collection of capillary blood using homeRNA correlates interferon and innate viral defense pathways with SARS-CoV-2 viral clearance https://buff.ly/3RyyK
Testing a new home collection blood sampling device (homeRNA) via microneedle patch to follow RNA transcriptomic signatures (gene expression) during infection.
Acute COVID-19 infection (n = 39) and healthy controls (n = 5)
Healthy uninfected people had no significant dynamic immune gene transcription.
COVID-19+ participants, on the contrary, had a robust response with over 418 dynamic genes associated with interferon and innate viral defense pathways.
Distinct response signatures over time:
Unvaccinated individuals had higher innate antiviral responses, interferon signaling, and cytotoxic lymphocyte responses
Breakthrough (vaccinated) infections showed lower interferon signaling and enhanced early cell-mediated response.
IFI27, a key viral response gene, tracked closely with SARS-CoV-2 viral clearance.
Animals:
1/31/23 PNAS: White-tailed deer (Odocoileus virginianus) may serve as a wildlife reservoir for nearly extinct SARS-CoV-2 variants of concern https://buff.ly/3WZ2lvr
Divergent SARS-CoV-2 variants of concern (VOCs; Alpha, Delta, and Gamma) are co-circulating in white tailed deer (WTD), long after their last detection in humans.
The deer may serve as a reservoir for variant SARS-CoV-2 strains that no longer circulate in the human population.
1/31/23 MedRxiV: Probable transmission of SARS-CoV-2 from an African lion to zoo employees https://buff.ly/3Jrt157
1/23/23 l: Comparative susceptibility of SARS-CoV-2, SARS-CoV, and MERS-CoV across mammals https://buff.ly/3XZ9bT9
SARS-CoV-2 is known to infect a broad spectrum of hosts including dogs, mink, ferrets, otters, hamsters, voles, deer, deer mice, bats, felines, and several nonhuman primates.
Comparative susceptibility of SARS-CoV-2, SARS-CoV, and MERS-CoV across mammals using in vitro cells cultured from 55 mammalian species that were challenged with pseudoviruses of SARS-CoV-2, SARS-CoV, and MERS-CoV.
Thomas’s horseshoe bats, king horseshoe bats, green monkeys, and ferrets may serve as reservoir hosts for these coronaviruses.
1/18/23 Lancet: Protective effectiveness of previous SARS-CoV-2 infection and hybrid immunity against the omicron variant and severe disease: a systematic review and meta-regression
Meta-analysis
Individuals with hybrid immunity (vaccinated and had a COVID infection) had the highest magnitude and durability of protection.
Hybrid immunity: People who are vaccinated and have previously been infected with COVID-19 had a 97% reduced chance of severe COVID-19 infection 1 year after their last vaccination or infection.
The effectiveness of hybrid immunity following primary series vaccination against reinfection waned to 41.8%...at 12 months,” while “effectiveness of hybrid immunity following first booster vaccination waned to 46.5%...at 6 months.”
2/1/23 NEJM: Humoral Innate Immunity and Acute-Phase Proteins https://buff.ly/3wPEjZu
Review of the innate immune system and how it affects COVID.
Figure 2. Innate Immunity — a Cellular Arm and a Humoral Arm.
Figure 3. The Cytokine Cascade and Cellular Sources and Functions of Acute-Phase Proteins.
2/1/23 Nature: The next generation of coronavirus vaccines: a graphical guide
The future of COVID vaccines needs to include nasal vaccines for mucosal immunity and universal vaccines that are variant proof.
"Immune response comes from B cells, which produce antibodies that can block SARS-CoV-2 from infecting cells, and from T cells, which can destroy infected cells (and support other immune responses).
The vaccinations also generate a pool of ‘memory cells’ for prolonged immunity, even after initial antibody levels dwindle. On subsequent infection, memory B cells begin proliferating and differentiating into cells that churn out more antibodies."
