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.
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 Brookings Institute, 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 low of 6% was found by Dr Ziyad Al-Aly 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 study from the Netherlands, 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, occurring in up to 70% of individuals.
A report by 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.”
Long COVID-19 occurs more frequently in those who have been hospitalized but can also occur all too frequently in those not hospitalized.
The CDC reports 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 disturbing encounter 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 symptoms appear to be additive 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 were 4 to 6 times less likely 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 delayed consequences and even death. 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.