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

Kevin Kavanagh, MD

In the beginning of the Omicron surge, the COVID-19 deniers were stating that no one died of the Omicron. At the end of the wave, the United States had 

® warned in an article entitled “Omicron’s Mild Symptoms Can’t Mask Danger It Poses” that “those who are not vaccinated or immunosuppressed are at risk for severe disease.” On Dec. 20, 2021, Reuters reported that “infections caused by the Omicron variant of the coronavirus do not appear to be less severe than infections from Delta, according to early data from the UK.” Despite the early warnings, reporting on infections being more benign with a lower-case fatality rate continued in most of the news media. This month, a definitive study from Harvard and the Massachusetts General Hospital concluded that the “Omicron variant is as deadly as previous waves after adjusting for vaccinations, demographics, and comorbidities.”

The confusion occurred because Omicron’s case-fatality rates are biased with the inclusion of a large number of vaccinated individuals. If someone concluded that the disease from Omicron was less severe, and thus, they do not need to become vaccinated and protect themselves, then they might have made a fatal error and, at the very least, increased their risk of developing long COVID-19.

For those who have not recently recovered from an infection or let their vaccination immunity wane, their chances of dying or getting long COVID-19 by undertaking a risky activity is far too high. One must remember that even with a low case fatality rate, very high infectivity can overcome the lower virulence by producing a large number of severe cases. Thus, their chances of getting sick during an event is a combination of the infectivity and virulence of the virus; and infectivity increases the chance of severe illness exponentially.
 
Unfortunately, one’s protection from an infection is not durable. The virus mutates and immune escape variants emerge. This appears to have happened in South Africa with the BA.4 and BA.5 variants. An estimated 90% of the population of South Africa has been exposed to Omicron, and they are still undergoing another surge with the new variants (See Figure).
 


BA.4 and BA.5 are thought to be 36% more infectious than the BA.2 Variant and effectively evade immunity. The severity of the disease is not known. Initial reports from South Africa indicate that severity is similar to Omicron; however, the accuracy of reporting from South Africa, similar to Sweden, has come under fire. An article in The Lancet reported South Africa’s excess death rate to be 3.31 times higher than their COVID-19 death rate—one of the highest ratios in the world.

The immediate outlook for the United States warrants concern. 

 in the last week with hospitalizations increasing 9%. This increase is fueled by the BA.2 variant and its more infectious offspring, BA.2.12.1. The BA.2.12.1 variant is more infectious than BA.2 and currently 

comprises 36% of sequenced cases in the United States

 the BA.4 and BA.5 variant in 14 states and is likely already in every state in the nation. Although only a few cases have been reported and these variants comprise only a small minority of sequenced cases, individuals need to react now. especially because the United States does not have the best 

 for variants with “some European countries and even South Africa have better sequencing capabilities than the U.S.” Because of these risks, the CDC has restated their recommendation to wear 

, and individuals may need to reevaluate the wisdom of holding large events such as the White House Correspondence Dinner. The latter may well be another super spreader event with 

 agencies testing positive for the virus.
 
Although many individuals measure success by the number who die of COVID-19, the ravages of long COVID-19 are deeply disturbing. The United Kingdom’s Office for National Statistics estimates that 10% to 25% of COVID-19 survivors may develop persistent symptoms. A recent study from the 

 found that “78% (of patients with long COVID-19) reported difficulty concentrating, 69% reported brain fog, 68% reported forgetfulness, and 60% reported problems finding the right word in speech.” Further, COVID-19 causes 

 to what occurs between the ages of 50 to 70, equivalent to losing 10 IQ points.
From Dec. 2021 to Feb. 2022, the seroprevalence in the United States from 

 Since that time, many more infections from Omicron have occurred. In addition, 66% of the United States citizens are currently “

.” Thus, almost everyone in the United States has had some exposure to SARS-CoV-2. If herd immunity can be achieved, then the United States should have achieved it. If another surge occurs, unfortunately, those numbers may be the status quo.

With new variants emerging, cases rising and a more complete understanding of the dangers of long COVID-19, one can make a strong case for resuming public health measures intended to control spread and infections from this disease. Unfortunately, even in the face of waning immunity, few individuals in the United States are currently wearing masks, and many are continuing to engage in risky behavior. This may well be a toxic mix, and healthcare facilities, and infection preventionists need to prepare for another possible surge in cases.



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Few individuals in the United States are currently wearing masks, and many are continuing to engage in risky behavior. This may well be a toxic mix, and healthcare facilities and infection preventionists need to prepare for another possible surge in cases.   

AB.4 and BA.5 Variants, Pandemic Fatigue, and Waning Immunity: A Toxic Mix 

As the United States continues to open and drop mandates, the BA.2 variant of SARS-CoV-2 is surging in many countries in Europe. The growing consensus is that this variant could be up to 

 than the BA.1 or the Omicron variant. The variant has become the dominant strain in the United States and as of April 2, 2022, comprising 

.

There have been many news reports citing early data that indicate BA.2 has the same virulence as the Omicron variant (BA.1). This consensus occurred despite laboratory evidence showing the virus has a greater propensity to attack the lungs and 

. This animal evidence was largely discounted despite the lauding of data from a similar animal model which was used to predict that the Omicron variant was less virulent than the Delta variant.

Source: GOV.UK Coronavirus (COVID-19) in the UK

New data is beginning to emerge for the BA.2 variant, and the results do not look good. Data from the United Kingdom show the BA.2 surge to be about half that of the Omicron surge. However, the 

 and those caused by BA.2 may eventually surpass Omicron (see Figures). This evidence indicates that BA.2 is not only more infectious but also more virulent than the Omicron variant. It should be noted that the UK National Health Service Data has not yet been affected by the 

discontinuation of the United Kingdom’s testing program

 on April 18. However, in the near future expect to see a marked decrease in reported cases, which may not reflect a true reduction, just reduced access to testing. 

The BA.2 variant also may evade immunity to a greater extent than the Omicron Variant. 

 for the Vir Biotechnology Inc. and GlaxoSmithKline monoclonal antibody product that was effective against Omicron but not the BA.2 variant.

Source NHS England: Statistics >> COVID-19 Hospital Activity

In the United States, cases are no longer dropping. Nationally, the case rate appears to have reached bottom and, in several states, cases are increasing. As of April 5, 2022, 

 show the 14-day change in cases is rising in Nevada (+104%), Nebraska (+102%), Massachusetts (+72%), Connecticut (+70%), New York (+62%), New Jersey (+50%), and Washington, DC (+45%).
 
Neither natural infection or a 2-course mRNA vaccine provides adequate protection as immunity wanes over time. Those who have had a recent Omicron infection may have greater protection. However, with only 66% of the United States’ population being fully vaccinated and 

, our country may be on the verge of a significant surge in both cases and hospitalizations. It is imperative for all eligible individuals to become vaccinated and obtain a booster.

Evidence shows the BA.2 variant is more infectious and virulent than the Omicron variant.

Viewpoint: New UK Data Show BA.2 Variant Produces More Frequent Hospitalizations Than Omicron

One of the most discussed topics has been how the United States’ COVID-19 response compares with the rest of the world. Being one of the richest and most developed nations in the world, the United States should have had one of the best responses. The often-quoted statistic is that we have more SARS-CoV-2 cases than any other nation in the world, currently over 

. However, when one adjusts for population, the United States drops to the 49th worst nation, which is still not very good.

But then, the United States also has an organized reporting system, and its poor ranking may be because of robust reporting and thus, recording of more cases. In some countries, a positive COVID-19 test is required for a diagnosis, and in many nations, those are in very short supply.
 
Another metric that can be used to measure a country’s performance is deaths. One may state that patients in poor countries may not have access to their health care system and be more likely to die. However, in those countries, deaths may not always be reported; and our health care system is not, by many measures, the best in the world. We do not have universal health care and have reduced access for many of our high-risk citizens. According to the Commonwealth Fund, of 11 high-income nations, the United States is dead last in access to care, equity, health care outcomes, and overall 

. Unfortunately, in all of the categories but care processes, the United States vastly underperforms the next closest high-income country.
 
Recently, an important 

 regarding excess mortality during the COVID-19 pandemic. Excess mortality is determined by the number of deaths that are above a country’s average number of expected deaths as measured over previous years. Many lessons can be learned from this data. Although mortality rate is a different metric than cases, the 2 are closely related and comparable in countries with equivalent health care systems.

Table 1: Courtesy of Kevin Kavanaugh, MD.

Table 1 compares the Commonwealth Fund’s rankings for the 11 high-income countries and the rates of excess mortality per 100,000 population/per year. The United States has the highest rate of COVID-19 deaths per capita.

The assertion that the United States has performed the worst in the world is not true. Although several examples of third-world nations outperforming the United States exist, there are also many examples where this was not the case. Central and Latin America has a reported COVID-19 mortality rate of 124.1 per 100,000 per year. On face value, this rate is better than the United States’ mortality rate of 130.6. However, the excess mortality rate in Central and Latin America was 274.4 compared with the United States’ rate of 179.3. Thus, the observed low COVID-19 rate in Central and Latin America was probably due to underreporting. In contrast, Southern Latin America (Argentina, Chile, and Uruguay) outperformed the United States with a COVID-19 mortality rate of 129.0 and an excess mortality rate of 150.2. The closer approximation of excess mortality to COVID-19 mortality in Southern Latin America indicates that they possibly had a more robust and accurate reporting system.
 
Further, Sweden has also been a hot topic, since the perception in the United States is that they have done less and outperformed the United States. It is true that they did not implement all the strategies that were implemented in the United States, but they implemented many approaches, such as travel restrictions, limitations on the size of gatherings, social distancing, school closures, and work from home programs. The key difference from the United States is that Sweden had a much larger portion of its population adhere to these measures. In addition, Sweden has a higher ranked health care system (see Table 1) and a lower poverty level than the United States. Sweden’s population is also less likely to live in crowded tenement conditions and has greater access to their health care system.
 

Table 2. Courtesy of Kevin Kavanaugh, MD. 


Although Sweden’s excess mortality is better than the United States’, compared with other Nordic Countries, many of which implemented more stringent measures, Sweden did not fare as well (see Table 2). Sweden has one of the highest excess mortality rates, only behind Denmark. Many of the Southeast Asian countries have very low excess death data, which is the result of their near zero COVID-19 policy. Of interest, as shown in Table 1, Australia and New Zealand have a negative excess death rate (-37.6 and -9.3 respectively). In addition, South Korea has an excess death rate of 4.4, Singapore -15.8, and Taiwan of -5.9. In other words, most of these countries’ populations lived longer than expected, possibly as a result of maximizing public health strategies. 

 study’s data acquisition period ended on Dec. 31, 2021, and many Southeast Asian countries are currently experiencing a very large BA.2 surge. BA.2 is highly infectious and is overcoming many public health strategies. Thus, these countries may well experience a very large surge, but if BA.2’s lethality is similar to Omicron’s, they may still have mitigated the large number of deaths that have occurred in the rest of the world.
 
The ratio of excess COVID-19 mortality to reported COVID-19 mortality in the United States is 1.37. This means that the increase in deaths that occurred in the United States was greater than the number of COVID-19 cases reported. In the United Kingdom, this ratio was 0.97. A decrease in some categories of deaths can occur during a pandemic, for example, from other respiratory illnesses. Thus, the United Kingdom’s reporting, on average, appears to be highly accurate. In my home state of Kentucky, this ratio was 1.68.
 
Overall, the data in 

 study regarding excess mortality does not support the contention that the United States has had the worst response in the world. This appears to be a statistical argument that does not consider the underreporting in many countries. However, the data does show that the United States is below average in the world and among the worst in the developed and high-income nations. We need to learn the lessons of this pandemic, reform our health care system, and improve messaging along with public acceptance of mitigation strategies. The United States can and must do better.



Other nations, such as Sweden and Australia, outperformed the US metrics. 

How Does the US Response to COVID-19 Compare With the Rest of the World?

As the Omicron surge subsides, many areas in the United States are rapidly returning to normal. Almost all agree we will face another surge of COVID-19 or another virus in the future. There are many lessons to be learned from the current pandemic, but the most important is how disinformation can divide a nation. Nowhere has this been more evident than the use of masking in schools.
 
At the heart of the misinformation spread by many who advocate against the use of masks in schools is that masks are not effective. Granted, they are not 100% effective, but the use of masks is one of the most important best practices to prevent the spread of disease. Unfortunately, this century-old practice has somehow become controversial in the last 2 years, despite mounting evidence that demonstrates its effectiveness with SARS-CoV-2.

On September 24, 2022, the CDC’s 

) published a report that clearly demonstrated the usefulness of school masking in Arizona’s 2 largest counties, Maricopa and Pima Counties, which comprise the metropolitan areas of Phoenix and Tucson. This 

 that schools which started the 2021-22 academic year without a mask mandate had 3.5 times the number of coronavirus outbreaks as in schools which started the year with universal masking. Another 

 that from July 1, 2021, to September 4, 2021, schools without a universal masking requirement “experienced larger increases in pediatric COVID-19 case rates after the start of school compared with counties that had school mask requirements (

 funded by the National Institutes of Health found that 6 school districts with optional masking had 3.6 times the secondary infection rate as 46 institutions with universal masking. This study confirms the 2020 work of 

., which reported rates of transmission of SARS-CoV-2 as a function of age. The investigators found that rates of secondary transmission to household contact was the highest for those aged 10 to 19 years. The next highest rate of secondary transmission was the 70 to 79 year age group. Secondary transmission is extremely important, since it is estimated that more than 

 in a multi-generational (3 or more generations) household, and grandparent caregivers are at the highest risk for severe COVID-19.

Despite the above evidence, many believe the disinformation regarding masks. The assertion that masks will not filter and block a 0.1-micron viral particle ignores the science that documents that the SARS-CoV-2 virus aerosolizes as small droplets which measure between 10 and 100 microns. The dry virus, as measured by electron microscopy, is not a major transmitter of disease between individuals.
 
Masking may hinder a student’s word recognition by hiding a speaker’s mouth and lips. However, to correct this problem would entail the teacher not wearing a mask. Teachers are more susceptible to COVID-19 than students, and 24% of teachers have a 

 for severe COVID-19. In addition, loud speech during a presentation has an increased propensity to aerosolize a virus. A solution to this problem may be the 

 which are being developed by Ford.

The March 2022 report “

Getting to and Sustaining the Next Normal. A Roadmap for Living with COVID

,” from the Colton Foundation and the Rockefeller Foundations’ Pandemic Prevention Institute, concluded that “based on the extensive data and research…schools and childcare centers can safely remain open by following best practices”; and that “governments should not close schools and childcare facilities unless all other community mitigation measures fail.”

An excellent case study regarding a school district’s implementation of a multi-layered approach to remain open and prevent COVID-19 was written by 

®. The mitigation strategies included masking, surveillance testing, case identification and tracking, vaccinations, and improvements in ventilation.
 
The highly infective Omicron Variant (BA.1) poses significant challenges to control its spread. Most experts now advocate using KN95 or N95 masks instead of the cloth variety which were found effective with previous variants. The “Stealth Omicron” BA.2 variant may be even more challenging. This variant could be up to 30% more infectious than BA.1 and is thought to be causing the current uptick in SARS-CoV-2 cases in the United Kingdom, where 

 over the last 14 days.

Above all, as pointed out by the “

Getting to and Sustaining the Next Normal

” report, we need clear guidance on when school mitigation recommendations (“including masking, social distancing, quarantining, reduced class sizes, and outdoor learning”) are to be triggered to enable communities to provide the safest environment possible for the education of our children.

Multiple studies and reports show that masks in schools are effective, safe, and necessary because COVID-19 is not going away. 


Evidence Shows Students Need to Wear Masks in Schools Despite Disinformation

 with SARS-CoV-2 experience a loss of smell and taste (it should be noted that the perception of taste is markedly affected with the loss of smell). Many have assumed this symptom is because of nasal congestion or damage to the nerve receptors in the nose. However, data from a recent study published in the journal 

 support a more chilling prospect—that this symptom is caused by spread of the infection to the brain’s olfactory cortex, and from there the virus can spread to other structures causing memory and cognitive impairment.
 
The newly 

 by Gwemaëlla Douaund, et al., documented changes in brain scan images of patients with SARS-CoV-2. Some of the most telling findings were a reduction in grey matter thickness in the orbitofrontal cortex and “tissue damage in regions functionally-connected to the primary olfactory cortex,” along with a reduction in brain size. The orbitofrontal cortex has extensive connections to the olfactory cortex and limbic system structures involved in memory and emotions. Damage was more extensive in the 15 patients who were hospitalized but, even with their exclusion, there was still a significant cognitive decline in the SARS-CoV-2–positive patients. The lasting clinical impact of these changes is not known, but some are concerned that they may contribute to the onset of Alzheimer disease. The authors note that these changes represent statistical averages and “not every infected participant will display brain longitudinal abnormalities.”

Many articles have been written on the crippling pulmonary effects of COVID-19. But 

 on the heart and central nervous system (CNS) are of grave concern. Early in the pandemic, frequent anecdotal reports of brain fog and difficulties with concentration started to surface and were common symptoms in patients afflicted with long COVID. Overall, between 

 with COVID-19 develop long COVID.
 
The frequency of CNS and cognitive symptoms has been reported by a number of authors using a variety of experimental designs and surveys.
 
One of the first clinical studies regarding SARS-CoV-2’s effect on the brain was published in July 2020 by 

 The investigators studied 43 patients with COVID-19 (“29 were SARS-CoV-2 PCR positive and definite, 8 probable, and 6 possible”) and found inflammatory CNS syndromes in 12. The authors concluded that “SARS-CoV-2 infection is associated with a wide spectrum of neurological syndromes affecting the whole neuraxis.”

., observed that symptoms of COVID-19 can last up to 9 months in 30% of 177 patients. Additionally, 85% of the patients were outpatients with mild disease. The most common symptom was fatigue, which was reported in 13.6% of the total patients (24 of 177) and brain fog which was reported in 2.3% of the total patients (4 of 177).

In June 2021, 

., reported long-term sequelae in 61 home-isolated patients with COVID-19. At 6 months, 52% had persistent symptoms (32 of 61), with 13% (8 of 61) reporting impaired concentration and 11% (7 of 61) reporting memory problems.
 
In July 2021, 

. reported the results of an online survey of self-reported patients with COVID-19. Long COVID-19 was defined as symptoms persisting greater than 1 month after the initial diagnosis. The NIH/NINDS PROMIS Quality of Life in Neurological Disorders survey results were analyzed from 999 respondents. A total of 76 (7.6%) reported having COVID-19. The investigators found prolonged symptoms existed in 25% of patients with COVID-19 and that neuro quality of life cognitive dysfunction was more than 11 times more common in the COVID-19–positive group. Of the 19 patients with long COVID, 42% reported experiencing “brain fog.”
 
Also in July 2021, a large online survey by 

, studied 3762 patients with COVID-19 symptoms lasting more than 28 days. The authors reported 85% of respondents (3203) experienced “brain fog and cognitive dysfunction, including poor attention, executive functioning, problem solving, and decision making.” In addition, 72% experienced memory impairment.
 
As time progresses, it is becoming more apparent that prevention of the dangers and disability of long COVID should be of paramount importance. The prevention of hospitalizations and severe COVID-19 as a primary goal is no longer acceptable. We must also prevent the occurrence of long-term pulmonary, cardiac, and central nervous system disability. The peer-reviewed study by Gwemaëlla Douaund, et al., supports the conclusion that the “brain fog,” as reported by many who have recovered from mild infections, is real and has an anatomical basis.

Unfortunately, the COVID-19 pandemic does not appear to be over. SARS-CoV-2 cases in the United Kingdom have recently started to tick upward, and the country’s 7-day hospitalization rate has 

. The United States has all but declared victory and followed the United Kingdom’s example by rapidly relaxing public health strategies, including masking. The BA.2 (Stealth) variant could prove more infectious than Omicron (BA.1) and is ravaging Denmark and Hong Kong. This variant is also increasing in our country. A finding that, combined with the increased concerns over the impact of long COVID, dictates that a more careful approach to relaxation of mitigation strategies may be warranted.

A new study supports the conclusion that the “brain fog” reported by many who have recovered from mild COVID-19 infection is real and has an anatomical basis.


COVID-19 Brain Changes: New Evidence Details Long-Term Effects of Infection

Mounting evidence is supporting the spread of SARS-CoV-2 in animals. The latest report is from Ontario, Canada, and has added to the 

 that white-tailed deer can become infected with SARS-CoV-2. This report comes on the heels of another 

 documenting spread of the Omicron variant in Staten Island deer. SARS-CoV-2 was 

 to infect white-tailed deer on January 12, 2021. This first report was also from Ontario, Canada. 

 have found SARS-CoV-2 in up to 82.5% of deer (80 of 97 samples) in Iowa; and in 

 in Michigan, Pennsylvania, Illinois, and New York.
 
The recent study from Ontario presents several disturbing findings. The SARS-CoV-2 virus found in the deer was a highly mutated virus, with 49 mutations compared with the closest known strain in humans. This is “suggestive of sustained viral transmission.” In other words, the virus may have found a stable host or reservoir in the white-tailed deer population. The authors also point out that there are significant human-to-deer interfaces, along with interfaces with other wildlife.
 
The authors believe the newly detected Ontario white-tailed deer virus (Ontario WTD) may have its distant ancestor from a lineage identified in Michigan. Thus, the Ontario WTD likely represents a case of spread from humans to deer.

Of concern is that the authors also presented information that supports a case of deer-to-human spread of this highly divergent variant. The human case had “highly similar mutations” as the Ontario WTD virus, occurred in the same region as the infected animals, and the patient also had known close contact with white-tailed deer.
 


 animal SARS-CoV-2 infections and the possibility of animal hosts on August 5, 2021. Spread of the virus in animal hosts was 1 of mechanisms of virus evolution, which was 

 by the United Kingdom’s Scientific Advisory Group for Emergencies (SAGE).

We cannot assume that white-tailed deer are the only animal hosts (or virus reservoirs) or that deer were exposed directly from humans. There could be an intermediate host. Dogs, cats, bears, gorillas, baboons, snow leopards, minks, and rodents 

 in the emergence of the Omicron variant (this variant carries 7 out of the 7 mutations that promote transmission in rodents).
 
There are several important lessons here:
1. The virus is spreading easily outdoors among deer. The same should be true with mankind. Droplet spread can still occur outdoors if you are within 6 feet of someone.
2. An animal host all but guarantees that herd immunity in humans will not eradicate the virus.
3. The variants arising in animals will have no regard for the lethality in humans. Thus, increases and decreases in the variant’s human case fatality rate will be random. The virus does not need humans to live and evolve.
 
Above all, the report by Bradley Pickering et al underscores the importance of 

, the idea that animals and mankind live in the same biosphere and you cannot optimally promote health in mankind without also addressing the health and spread of disease in animals. It is unlikely we can stop the emergence of future dangerous variants by vaccinating all of mankind. We must also address the health of animals and modify how we interact with domesticated and wild species.

The virus may have found yet another stable host in the white-tailed deer population. 