KEVIN KAVANAGH, MD, is the founder of the patient advocacy group Health Watch USA

Kevin Kavanagh, MD

 for blood clots in his leg, which embolized to his lungs, is a sobering illustration of the long-term risks imposed by even a mild case of COVID-19, along with the reason why those who survive the acute infection should not be considered recovered. Al Roker recently recovered from a SARS-CoV-2 infection which caused what were termed “mild symptoms.” He was 

 on the Today Show in January 2021. This report follows the cardiac 

. Her husband reportedly contracted COVID-19 twice in a month and Julia Powell contracted the disease in mid-September. Ms. Powell was 

.

Many individuals are asking, are these reports just chance occurrences? Are these incidents due to the vaccine or to COVID-19? Recent reports point strongly to COVID-19. Clotting was a very rare risk factor for the 

, but not a significant factor with mRNA vaccines.

The evidence of these cases being a post COVID-19 sequela is rapidly mounting. A recent 

evaluated 48 million medical records from patients who resided in England and Wales. 1.45 million individuals had COVID-19. Those who had COVID-19 were 22 times more likely to have an arterial thrombosis and 33 times more likely to have an embolism during the first week of their acute illness. During weeks 27 to 49, after the onset of symptoms, there was still a 35% increase in clot formation and an 80% increase in embolism.

An early study, in June 2020, from Baylor College, reported that 

 admitted to their ICU developed clinically significant thromboses.

On April 6, 2022, 

 analyzed data from the Public Health Agency of Sweden on over 1 million Swedish patients who tested positive for SARS-CoV-2. During the first 30 days after acute COVID-19, there was a 5-fold increase in deep vein thrombosis and a 32-fold increase in pulmonary embolism.

On April 22, 2021, 

Al-Aly et al reported an overall delayed risk of thrombosis in COVID-19

 patients that was 39% higher 30 to 180 days after onset of symptoms. This risk increased to 11 times higher if the patient was hospitalized during the acute phase, and 26 times higher if the patient was treated in the ICU. A vivid reminder that if a patient is discharged from a hospital after COVID-19, they should not be considered “recovered” but instead should have continued close monitoring.

Overall, this post COVID-19 sequela is just one of many which contribute to delayed fatalities in COVID-19 patients. These sequelae are responsible for a 

delayed excess death rate in COVID-19 of 8.4 per 1000

 patients.

These events also illustrate why it is so hard to determine the exact fatality rate for COVID-19. At the beginning of the pandemic, there were complaints that people dying of heart attacks (coronary thrombosis, or a clot in the coronary artery) were being counted as COVID-19 deaths. As evidence mounts, this once considered ludicrous practice, was probably correct. In the end, excess death rates will need to be used to obtain a more accurate estimate of the pandemic’s toll.

The above is just another reason to take steps to be as safe as possible during the holidays. Remember, many relatives are elderly and at a very high risk for severe COVID-19 and Long COVID. All who are able should receive the bivalent BA.5 booster. Right before family gatherings, perform a rapid antigen test on all attendees. Ask visiting relatives to follow safe practices (wearing masks and avoiding crowded indoor settings) several days before the holiday events. No single practice will afford adequate protection, but all three will help provide the highest possible protection for a safe holiday.

Articles

As the festive holidays begin, even with vaccinations and boosters, COVID-19 still remains a concern for long COVID-19 and other severe long-term effects. 

As Holidays Approach, COVID-19 Remains a Major Concern

On Nov. 3, 2022, the Centers for Disease Control and Prevention (CDC) held their 

Healthcare Infection Control Practices Advisory Committee

 (HICPAC) meeting, which, although short, had extremely insightful discussion on lessons learned from the COVID-19 pandemic and discussions regarding a possible paradigm shift in the next generation of disease prevention recommendations.

Michael Bell, MD, from the CDC, presented an update regarding infections of concern. The first was monkeypox which is trending downward with good vaccine uptake in target populations. The second was Ebola which is spreading in Uganda. So far at least 150 cases and over 1000 people are being tracked. It was stressed that similar to SARS-CoV-2, it is important to recognize the infected patients before they enter a facility.
 
As discussed in a 

, the strategy of admission surveillance should be expanded to methicillin-resistant Staphylococcus aureus MRSA. Both the United Kingdom and the United States Veterans Healthcare Administration have had significant success in controlling hospital-onset MRSA infections using this intervention.

Not discussed was the record number of respiratory syncytial virus (RSV) infections which are currently 

. Social media is filled with the discussion of “immunity debt,” which I must admit I have before never heard of. I feel there is not a well-established scientific basis for this concept. The narrative is that this debt occurred because schools have been closed, immunity dropped, and now we have more RSV infections. This is wrong on two accounts. First, schools were not closed en masse last year. For example, according to the US Department of Education on the 

, there were 47.2 million students enrolled in in-person districts, 1.5 million in hybrid districts, and only 53.7 thousand in remote districts. In my state of Kentucky, no students were enrolled in remote districts. Second, so far this year we have had fewer—not more—RSV infections (see Figure 1). Thus, the RSV infections filling hospitals are not more common, but more severe.

https://www.cdc.gov/surveillance/nrevss/rsv/natl-trend.html


One hypothesis to explain this is the possibility that SARS-CoV-2 causes a persistent immunological dysfunction in infected individuals. Associated immunosuppression is commonly 

 infection, and immune dysfunction has been documented to 

“(persist) for 8 months following mild to moderate SARS-CoV-2 infection.”

 By February 2022, the CDC estimated that 

With the United States facing a triple threat of SARS-CoV-2, RSV, and seasonal influenza this year, the CDC has applied lessons learned during the COVID-19 pandemic to optimize strategies to prevent spread. The report from the CDC’s 

Isolation Precautions Guidelines Workgroup

, discussed draft proposals which outlined a new approach for disease prevention. (See Figure 2.) Sharon Wright, MD, MPH, from HICPAC, explained the old 2007 framework which had 3 transmission categories: transmission by droplet, airborne, and contact or touch. The 2022 proposed framework has 2 modes of transmission: air and touch. Transmission by air includes inhalation along with splash and spray.


Figure 2: Slide from CDC’s Nov. 3, 2022, HICPAC Presentation. Draft proposals which outlined a new approach for disease prevention.

 the old dichotomy of approaches in respiratory pathogen spread which was created with the classification of droplet and airborne spread. When, in reality, airborne particles have a continuum of sizes and even talking can aerosolize infectious particles.

It was also proposed at the Isolation Precautions Guidelines Workgroup, to condense transmission guidelines and uniformly apply many guidelines to all health care settings, rather than facility specific; for example, separate guidelines for acute care facilities, nursing homes, behavioral health, pediatric facilities, etc.

At the meeting Michael Lin, MD, MPH, from HICPAC, also presented data and a proposed framework for preventing transmission by airborne pathogens. There were no randomized trials, but 5 observational studies which favored the use of N95 masks with the prevention of SARS-CoV-2. The use of N95 masks in the SARS-CoV-2 pandemic has 

not been routinely followed by many facilities

this added protection is needed for staff and patients

The proposed redefinition of spread, uniform application of guidelines across different types of facilities, and the recommended use of N95 masks to stop the spread of SARS-CoV-2, if adopted, could provide revolutionary and needed changes in our approach to infectious disease, along potentially transforming our approach to the SARS-CoV-2 pandemic.


CDC discusses potential proposals to redefine spread and to produce uniform guidelines across different types of facilities because public health interventions do not cause immunological debt but instead may prevent immunocompromising infections. 

Respiratory Spread and the Flawed Concept of Immunological Debt: A New Understanding

The United States may be on the precipice of a rude awakening regarding the persistence and devastation of COVID-19. A perfect storm is brewing with the convergence of 3 untoward outcomes: The bivalent booster may primarily elicit imprinted immunity, a deadly brew of a plethora of immune escape variants is forming, and our public has thrown safety to the wind with few—if any—masking or bothering to optimize their immunity. All of this is in the background of new and disturbing data regarding the dangers of long COVID-19.

 from Columbia and the University of Michigan found that the immune response elicited by the new bivalent booster was similar to the old univalent booster for “all SARS-CoV-2 variants tested, including BA.4/BA.5.” This finding supports my concerns regarding the bivalent booster and the phenomenon of immune imprinting or “antigenic sin.” In other words, the type of immune response you produce is based upon the virus you were first exposed to (whether through vaccination or infection) and future exposures do little to modify the type of response elicited. A second study

 from Harvard also found comparable BA.5 antibody titers with the monovalent ancestral and bivalent boosters.

COVID-19 Variant compared with their fold evasion. (Credit: Stuart G. Turville) 


 
I first discussed this concern in an 

regarding data presented before the Centers for Disease Control and Prevention's (CDC’s) September 2022 Association for Professionals in Infection Control and Epidemiology committee meeting. The safety of the booster has never been in question. What is debated is if it will be any more effective than the booster based upon the ancestral strain. The presented data, which was derived from mice, found that the monovalent BA.5 booster (which is not clinically available) produced a response to the ancestral strain which was similar to that of the ancestral monovalent booster. However, the monovalent BA.5 booster produced a 6-fold increase in antibodies to the BA.5 variant, as the hybrid Ancestral/BA.5 booster (which is clinically available) produced a 2.6-fold increase. With this data, one must wonder why the univalent BA.5 booster was not chosen for clinical use.
 
But this finding was in mice. The human laboratory data reported by the University of Michigan found that the response elicited by the bivalent booster was similar to the response elicited by the bivalent Ancestral/BA.5 booster for all SARS-CoV-2 variants.
 
This is not good news. The immune escape potential of the BA.5 variant and not having a refined immune response, places all of us at risk. What is even more concerning is that if our immune response is imprinted to the original virus we are exposed to, what will happen with the new, even more immune evasive variants which are in circulation? Currently, the BQ.1 and BQ.1.1 variants are even more evasive and comprise 27% of all sequenced specimens

 in the United States. The BA.4.6 and BF.7 are also slowly increasing their proportion in the reported specimens. And the XBB

variants are looming; both are circulating in the United States in low percentages. We are faced with a soup of variants

, which because of their high infectivity can search out the most suitable host to infect.
 
Stuart G. Turville, corresponding author of an article in 

 regarding the characteristics of variants, posted the following graph on Twitter derived from their data on immune evasion.

There are concerns that the BQ.1 and BQ.1.1 may not only be more infectious but also more lethal as compared to the BA.1 (original omicron) variant.
Almost solely relying upon a vaccine/booster whose effectiveness appears to be imprinted in the past, to combat a virus which is progressively evading immunity, is unlikely to be an effective plan. We need to enact other strategies, such as masking and curtailing activities in high-risk venues.

To this end, the new CDC commercial entitled ”Just In Time: Updated COVID-19 Vaccines,”

 appears to be counterproductive. The commercial is designed to encourage vaccinations. No one is wearing a mask, even in crowded indoor places. The message I fear that is being transmitted is that if you are vaccinated all will be well and you do not have to take other precautions.

A screenshot of the CDC commercial. No one has masks on. (Credit: CDC)


 
I know of 5 individuals who have recently contracted symptomatic COVID-19 after receiving the bivalent booster. All had truly mild symptoms and did not develop long COVID-19. But the latter is always a concern, and it is the reason why we need to continue vigilance even if boosted, and if one becomes infected to seek medical care to obtain an antiviral therapeutic.

Should the new bivalent booster help? The answer is most assuredly “yes” but it is only 1 layer of armor. We also need to take additional steps. This means continuing to wear masks in high-risk settings and avoiding indoor crowded places. Even with the new bivalent booster, it is unwise to place yourself, without a mask, in a crowded elevator.

Have you recovered from covid-19, or just survived? Infection Control Today. Accessed October 31, 2022. https://www.infectioncontroltoday.com/view/have-you-recovered-covid-19-just-survived-

Wang Q, Bowen A, Valdez R, et al. Antibody responses to Omicron BA.4/BA.5 bivalent mRNA vaccine booster shot. bioRxiv. Published online October 24, 2022:2022.10.22.513349. doi:10.1101/2022.10.22.513349

Collier A Ris Y, Miller J, Hachmann NP, et al. Immunogenicity of the ba. 5 bivalent mrna vaccine boosters. bioRxiv. Published online October 25, 2022:2022.10.24.513619. doi:10.1101/2022.10.24.513619

The autumn covid-19 booster is here: is it safe and effective? Infection Control Today. Accessed October 31, 2022. https://www.infectioncontroltoday.com/view/the-autumn-covid-19-booster-is-here-is-it-safe-and-effective-

CDC. Covid data tracker. Centers for Disease Control and Prevention. Published March 28, 2020. Accessed October 31, 2022. https://covid.cdc.gov/covid-data-tracker

The CDC is now tracking a new immune-evasive Omicron variant spiking in Ukraine that’s evading treatment. Accessed October 31, 2022. https://news.yahoo.com/cdc-now-tracking-immune-evasive-175321321.html

Callaway E. COVID ‘variant soup’ is making winter surges hard to predict. Nature. Published online October 28, 2022. doi:10.1038/d41586-022-03445-6

Aggarwal A, Stella AO, Walker G, et al. Platform for isolation and characterization of SARS-CoV-2 variants enables rapid characterization of Omicron in Australia. Nat Microbiol. 2022;7(6):896-908. doi:10.1038/s41564-022-01135-7

Just in Time: Updated Covid-19 Vaccines - :30. Accessed October 31, 2022. https://www.youtube.com/watch?v=W-vp45ItkkA

Despite study results that the univalent BA.5 booster produced much higher increase in antibodies, why was the hybrid bivalent Ancestral/BA.5 booster with a significantly lower increase chosen to be distributed, and how does this put the population at risk? 

 Is the Current Bivalent Booster the Correct One? Studies Suggest it Isn't

Two of the greatest misinformation sound bites about COVID-19 are that once you leave a hospital, you have recovered, and if you have not been hospitalized, you have “mild” disease. These misstatements have had profound negative effects regarding our goals for vaccine effectiveness and implementation of prevention strategies.
 
What these statements do not consider are the long-term disabling effects of long COVID-19, a condition which appears to be occurring all too frequently. According to the 

, 2 to 4 million workers or approximately 2% of the United States Workforce is not working because of long COVID-19.

The incidence of long COVID-19 developing in COVID-19 patients varies greatly between papers. A 

 et al, when studying outpatient veterans with COVID-19. Most reports fall between 10% to 30% depending upon the cohort being studied. A recent controlled 

, found 1 of 8 patients reported symptoms of long COVID-19. The Netherlands’ study may be an underestimate, since it did not track brain fog and cognitive ability, which is now known to be one of the most frequent manifestations of long COVID-19, 

Hastie Claire et al. in Nature Communications

 monitored 31 thousand symptomatic infections at 6, 12, and 18 months post infection. Six percent of patients reported that they have not recovered, and 42% reported only partial recovery. And the symptoms of long COVID-19 appear to be persisting. After 6 months, for most, recovery status appeared not to change with “13% reported improvement over time and 11% deterioration.”
 


 more frequently in those who have been hospitalized but can also occur all too frequently in those not hospitalized.
 
The 

 an incidence of long COVID-19 of 14.2% (symptoms lasting 3 months or longer) and that long COVID-19 occurs more often in the young (14.9%), than those individuals above the age of 70 (6.4% to 8.1%).
 
The young have been observed to have a greater incidence of long COVID-19 than the elderly. This is not necessarily because they have a propensity to develop the disease, but because they are less likely to be vaccinated and boosted.

Repeated COVID-19 infections do occur and have been occurring with increased frequency. We are approaching our 3-year pandemic anniversary, and few would expect natural immunity to last this long with preexposure to the same variant. Unfortunately, with the frequent emergence of immune escape variants, such as Omicron and BA4.6, reinfections commonly occur. Boosters and vaccines give a degree of protection, but for high-risk individuals and the elderly, boosters are presently being administered every 5 months.

With the high infectivity and mutation rates of the new variants, we are all going to become infected with SARS-CoV-2. The main questions are how severe will the infections be, and how many times will one become infected?

A 

 occurred between CNN’s Pamela Brown and Dr. Anthony Fauci on Oct. 9, 2022.

Pamela Brown: “I've had recurring infections. Both times I've had COVID[-19] were not fun. Symptomatic both times.” On quoting an article in The New Yorker, Ms. Brown stated: “…that means many of us could get COVID[-19] 10 times or more in our lifetimes. “On asking if this was an accurate guess or projection, Dr. Anthony Fauci replied: “I think he said it, or she said it very well. It's really just a guess, and you really can't tell.”

Unfortunately, damaging long COVID-19 can also occur with repeated infections and the 

 to residual symptoms from previous infections. This finding combined with the long-term persistence of long COVID-19 systems, does not bode well for the United States’ workforce.

Vaccines are important in mitigating long COVID-19. Hastie et al, reported that people vaccinated pre-COVID-19 were 42 to 24 percent less likely to report persistent problems in smell, taste, hearing, appetite, balance, confusion, concentration, anxiety, and depression. A large National Institutes of Health study researching COVID-19 to Enhance Recovery (RECOVER) found that pre-COVID-19 vaccination 

reduced the chance of developing long COVID-19 by 30% to 38%

.
 
Simon et al, reported that unvaccinated individuals given a vaccination within 4 weeks after an acute infection 

 to report multiple symptoms of long COVID-19; those given a vaccination 4 to 8 weeks after the acute illness were 3 times less likely to develop long COVID-19 symptoms.
 
Ventilation is also key in stopping airborne pathogens. At a recent 

White House Summit on Improving Indoor Air Quality

, Dr. Joseph Allen from the Harvard T.H. Chan School of Public Health, stated “the original sin of the COVID[-19] response is the failure to recognize airborne transmission as the dominant mode of transmission….” Dr. Allen stressed that we spend approximately 90% of our time indoors and “the single biggest structural change we can make as a society is to do for indoor air what we've done for water quality.” Measuring CO2 levels is a good proxy for adequate ventilation. Handheld portable CO2 monitors can be obtained from between $100 to $150. Air quality is also important in maintaining good academic performance and concentration of both students and employees. As CO2 increases, the ability to concentrate decreases.
 
To stop the spread of highly infectious 

SARS-CoV-2 upper room germicidal UV lighting should be installed.

 This is a cost efficient technology which has been around for decades. It also has an excellent safety profile in that it uses UV-C light which has much less propensity to penetrate the skin.
 
What can infection preventionists do? First, stop referring to patients who have left the hospital as “recovered.” They need to be counseled to the possibility of persistence of their present symptoms and possible emergence of new ones. COVID-19 is a multi-system disease and can affect multiple organs of the body with 

. This includes coagulopathies, heart disease, and endocrine dysfunction. Second, encourage vaccinations and boosters. These will lessen the chances of hospitalization and death, and if one gets infected, lessen the chances of developing Long COVID-19. Third, all staff should wear fitted N-95 masks and patients given non-fitted N-95 masks. Finally, monitor your facilities’ ventilation with CO2 levels as a surrogate for adequate ventilation, MERV-13 filters should be installed, and to prevent the spread of highly infectious airborne pathogens, upper room germicidal UV-C lighting should be installed.
 
Above all, we must realize the pandemic is not over. Our work has just begun.
 



The additive effects of long COVID-19 with repeat infections, combined with the long-term persistence of long COVID-19 systems, does not bode well for the United States’ workforce. N95 masks, vaccines, boosters, and improvements in ventilation are keys to prevention.   

Have You Recovered From COVID-19, or Just Survived?

Alpha, Beta, Gamma, Delta, Omicron COVID-19 variants (Adobe Stock)

 for SARS-CoV-2 which contains the spike protein of the Ancestral Strain (original 2020 strain) and the BA.4/5 variant. On September first, the Centers for Disease Control and Prevention (CDC) recommended the administration of the newly reformatted Pfizer/BioNTech booster for individuals 12 years and older. The reformulated Moderna booster was recommended for adults 18 years and older.
 
The reformulated booster appears to be safe, and much needed in 

 a day from COVID-19 and the growing dangers of long COVID-19 with each reinfection.
 
While some controversy surrounds the booster, much of this is unfounded. There have been 2 clinical human trials for SARS-CoV-2 boosters—1 for the Ancestral Strain, and the other for a bivalent booster which also incorporated the BA.1 spike protein. The BA.1 booster clinical trials took months to complete. Meanwhile, the virus was not complacent, it continued to mutate, from BA.1 to BA.2 to BA.2.12.1 to BA.4/5. By the time the clinical trial was completed, the virus had undergone 3 major evolutions.


Figure 1.  Omicron BA.4/BA.5 Monovalent and Bivalent Boosters in Mice (Courtesy of Centers for Disease Control and Prevention) 


All data to date has shown the vaccines to be effective in preventing severe disease and hospitalizations. Because of the immune escape potential of the BA.4/5 Variant, the FDA asked Pfizer/BioNTech and Moderna to reformulate the vaccine to instead of including the BA.1 spike protein to incorporate the BA.4/5 spike protein (BA.4 and BA.5 have the same spike protein). According to the September first 

CDC Advisory Committee on Immunization Practices (ACIP) meeting

, there are only 10 changes in the genome between the BA.1 and BA.4/5 spike protein. Otherwise, the BA.1 and BA.4/5 bivalent vaccines are identical. The 

 and is administrating the bivalent BA.1 vaccine.

Why did the FDA ask for the reformulated BA.4/5 booster? It is probably because the immunity elicited by the BA.1 strain is weak at best, and one can easily argue the BA.1 wave was the most devastating to date due to its high infectivity. Nationally, it caused 

, and the anticipated silver lining of a large number of people becoming immune to SARS-CoV-2 did not occur. According to the University of Washington Institute for Health Metrics and Evaluation, infection with the Ancestral, Alpha and Delta Variants confers a 78% protection against reinfection at 40 weeks. This, however, 

drops to only 29% with the Omicron Strain

 (B.1.1.529, B.1.1.529.1, B.1.1.529.2).
 

Figure 2. Confirmatory Study: Omicron BA.4/BA.5 Monovalent and Bivalent Boosters in Mice (Courtesy of Centers for Disease and Prevention) 


Antibody levels elicited by univalent and bivalent BA.4 boosters have also been measured in mice. The research was presented at the September 1, 2022, CDC ACIP meeting by Kena Swanson, PhD, vice president, Viral Vaccines Research and Development at Pfizer. The results found that the BA 4/5 monovalent and bivalent vaccines greatly outperformed the Omicron BA.1 monovalent vaccine. The BA 4/5 boosters outperformed the original Ancestral Strain booster in the production of antibodies to BA.4/5. 
At a dosage of 1.0 mcg, the monovalent booster increased neutralizing antibodies by approximately 6.2 fold and the bivalent by 2.6 fold. (See Figure 1.)

Of interest is that the BA.4/5 boosters also produced robust antibody production to the wild-type or Ancestral Stain, even greater than that produced to the BA.4/5 Variant. The reason for this may be the phenomenon called “antigenic sin.” (It is not actually a “sin” but that is what it is called.) “Antigenic sin” imparts the biological advantage of being able to rapidly respond to a similar variant without starting antibody production from the beginning. But it also can mean that the maximum boost in immunological response may be to the virus that an individual is first exposed to.
 
At a lower booster dosage (0.5 mcg), the results of the different boosters were similar except for antibody production to the BA.2 Variant. (See Figure 2.)

Thus, ample safety data and immunological response data indicates the reformulated boosters to the BA.4/5 Variant will provide an improvement in efficacy. The magnitude of this improvement is not known, and the mitigation of this augmentation due to “antigenic sin” is also not known.

In retrospect, it may have been better to have produced and distributed a monovalent BA.4/5 booster which relies on “antigenic sin” for the augmentation of immunity to the Ancestral Variant. No one really knows.
 
Similar to the flu vaccine, to maintain efficacy, there is no time for clinical trials prior to vaccine production and administration. However, efficacy will be tracked post distribution. One thing is almost certain, if production is delayed and another immune-escape variant occurs, vaccine efficacy will fall, and recently variants have been occurring every 1 or 2 months.
 
In the beginning of the pandemic, mRNA vaccines were heralded as a major breakthrough allowing rapid adaptation and distribution of a reformulated vaccine. To accomplish this feat in 2 months is just remarkable and validates the initial optimism for this technology.

All and all, I feel a monovalent vaccine booster for BA.4/5 may have been better. However, the current authorized BA.4/5 bivalent booster promises to give much better protection to the BA.4/5 variant than the original booster. It has been 4 months since my last booster, and I will be first in line to receive the newly reformulated version.

Starting September first, the first of the autumn boosters began to be available, but individuals may be concerned about their efficacy and safety. Infection Control Today® looks at the data. 


The Autumn COVID-19 Booster Is Here: Is it Safe and Effective?

Last week the Centers for Disease Control and Prevention (CDC) 

 which I feel neither control or prevent a rapidly evolving and disabling disease, COVID-19. Many of the relaxations appeared to be timed with the opening of schools, ignoring the high rate of COVID-19 related hospitalizations, national deaths hovering just under 500 per day, and the urgent need for a reformulated vaccine, whose delivery is expected in the 

.

The relaxed guidelines no longer recommend those individuals exposed to COVID-19 participate in test-to-stay programs in schools. They no longer restrict the mixing of children in different classrooms, and they eliminated social distancing recommendations. In addition, there is no need to quarantine after exposure to the virus, and there are 

no longer recommendations for routine screening

 of individuals without symptoms.
 
Previously, the 

 for recommending that during the BA.4/5 surge an individual only needs to isolate for 5 days and if asymptomatic for 1 day, can intermingle with the public as long as the individual wears a mask. However, 

 still support 10 days of isolation after infection.
 
The irony is the latest round of CDC relaxations comes at the same time as the Food and Drug Administration (FDA) released guidance that an individual should have 3 

 before one can be assured that you are not spreading the virus. A study from Yale University found that routine testing of participants immediately before an event 

, and research from Harvard and the Boston Public Health Commission has reported that schools that abandoned masking requirements had an increase in COVID-19. 

This increase accounted for 30% of the COVID-19 cases

 in the school districts.

All these changes are all happening in the backdrop of a flood of studies detailing the dangers of long COVID-19. The Netherlands recently released a controlled study which 

found 1 in 8 patients developed long COVID

-19. The Brookings Institute estimates that 2.4% of the United States’ workforce is 

-19. Similar data has been produced in the United Kingdom where according to the United Kingdom’s “Office for National Statistics cited by Saunders, 1.9% of the adult UK population—1.2 million people—report that their activity is limited ‘to an extent’ or ‘a lot’ by long COVID-19,” and that long COVID-19 is a main driver in the 

UK’s work forces shrinking by 440,000 workers

.
 
Long COVID-19 also does not spare children, and 

 have had SARS-CoV-2. The CDC recently released a study finding that children can develop long COVID-19, 

and those afflicted have higher rates of serious illness

, including myocarditis and cardiomyopathy (1.99 times more likely), thromboembolism (1.87 to 2.01 times more likely), Type 1 Diabetes (1.23 times more likely) and acute and unspecified kidney failure (1.32 times more likely).

The Idea of letting the virus rip through the community and depend upon vaccination and Paxlovid may not be prudent advice. Current vaccines are not preventing infections 

nor do they reliably prevent long COVID-19

Paxlovid because it has multiple drug interactions

 with common medications, including statins, ace inhibitors, beta blockers, warfarin, Plavix, and digitoxin. Unfortunately, those individuals at higher risk for severe COVID-19 are often on 1 or more of these medications.
 
Relaxation of guidelines may seem prudent in the short term, but it may well have devastating long-term repercussions. It is not possible to control spread of SARS-CoV-2 when individuals are not quarantining nor testing for asymptomatic carriers, and the isolation period for those infected may well be too short. New reports indicate that 

. Until one is available, it is best to maintain preventative strategies by using N95 masks in indoor public settings, increasing indoor ventilation, and maximizing the use of testing.

Last week the Centers for Disease Control and Prevention relaxed recommendations which neither control or prevent a rapidly evolving and disabling disease, COVID-19. However, we must maintain effective efforts to control spread of the virus. 