#558 - COVID Vaccine, Long COVID, Elevating Your Kindness Quotient

From the Centers for Disease Control and Prevention (CDC)

1)  2024-2025 COVID Vaccine Recommendations

The CDC’s Advisory Committee on Immunization Practices (ACIP) has recommended the updated 2024-2025 COVID-19 vaccine for all people age >= 6 months, regardless of prior vaccination status. The CDC stresses the following important points in this recommendation:

• The specific products available for this recommendation are:
  • Moderna COVID-19 vaccine for ages 6 months and older
  • Novavax COVID-19 vaccine for ages 12 years and older
  • Pfizer-BioNTech COVID-19 vaccine for ages 6 months and older
• The updated 2024-2025 COVID-19 vaccine can be given as soon as it is available.
• The COVID-19 virus continues to evolve rapidly, and previously effective vaccine doses are rendered less effective by the virus’ mutations and time.
• The vaccine is intended to prevent serious outcomes of COVID-19 (death and hospitalization), including long COVID.

A summary of the evidence presented to the ACIP, and their subsequent deliberation is summarized on their website in the Evidence-to-Recommendation framework slides.

The highlights are:

• The risk of death from COVID-19 in the January 2024 wave was overwhelmingly among the >= 75 year age group followed by the 65-74 year age group. The only other group with significant mortality was the <= 6 months age group, for whom the vaccine is not recommended.
• COVID-19 has the highest hospital admission rate amongst the vaccine preventable diseases in children 6 months to 17 years.
• There are persistent racial/ethnic disparities in COVID-19 hospitalizations that primarily disadvantage American Indian/Alaskan Native populations followed closely by Black, non-Hispanic populations.
• Vaccine effectiveness in studies of the 2023-4 vaccines was in the mid-40% range for medically attended COVID and hospitalization, and ~23% for COVID death. As a reminder, vaccine effectiveness is the percent fewer people who will get the outcome if exposed to the virus (similar to a relative risk reduction).
• Safety data from the 2023-4 vaccines continues to be reassuring overall:
  • Myocarditis is a small risk, predominately in adolescent/young adult males, and seems to resolve quickly. There is a very small risk of persistent features on cardiac magnetic resonance imaging, the clinical relevance of which is poorly understood.
  • A stroke signal that was previously seen in reporting data did not bear out in Vaccine Safety Datalink studies.
  • Guillain-Barré syndrome occurrence rates in ages 65 years or greater are similar to other vaccines.
• Statistical modeling was used to assess the risk-benefit of a high-risk vaccination strategy (only those with comorbidities and/or age > 65 years) vs. a universal strategy. A universal strategy prevents approximately 30,000 hospitalizations per year. In addition, most of the adults in the United States have a factor that renders them high risk, which limits the ability to see differences in the strategies.
• There were a number of additional sociological, cost-effectiveness, and feasibility concerns researched, most of which supported or were neutral to a universal vaccination strategy.

John’s Comments:

The ACIP does quite a lot of study about the balance of benefits and harms and important contextual factors using its Evidence-to-Recommendations framework. Unfortunately, the data is always going to lag too long to help decision making when it is needed, so there are a lot of assumptions that must be made. These decisions are explicitly made and published, which is what is most important.

It's clear that even though we are “getting used to” COVID-19, it is still responsible for significant death, hospitalization and illness in the country, so routine vaccination is still a good strategy. We should reassure our patients that the safety monitoring of these vaccines is robust and ongoing.

References:

• CDC Newsroom. CDC Recommends Updated 2024-2025 COVID-19 and Flu Vaccines for Fall/Winter Virus Season. CDC. June 27, 2024. Accessed August 28, 2024. Link
• Panagiotakopoulos, Lakshmi. Evidence to Recommendations Framework: 2024-2025 COVID 19 Vaccines in Persons ≥6 Months of Age. Presented at: ACIP June 26-28, 2024 Meeting. Accessed August 28, 2024. Link

From the Literature

2)  Toward a Better Understanding of Long COVID

According to the World Health Organization (WHO), as of August 11, 2024 there have been more than 775 million confirmed cases of SARS-CoV-2 infection worldwide, and the actual number of those who have had the infection is likely quite higher, including many who have had multiple infections.  More than 4 years after the COVID-19 pandemic began, millions of people continue to suffer long-term sequelae of SARS-CoV-2 infection.  Many clinicians remain unsure of how to evaluate and manage individuals with post-COVID-19 syndrome, commonly known as long COVID. 

A recently published review article has attempted to provide updated information on this evolving syndrome.  The authors sought to bring together multiple streams of literature on the epidemiology, pathophysiology (including the hypothesized mechanisms of organ damage), lived experience and clinical manifestations, and clinical investigation and management of long COVID.  Although current approaches to long COVID care are largely designed to alleviate symptoms and optimize function, recent advances in clinical phenotyping, deep molecular profiling, and biomarker identification might herald a more mechanism-informed and personally tailored approach to clinical care in the near future.

Estimates of the incidence of long COVID after acute infection range from 50–85% for unvaccinated people who were hospitalized, 10–35% for unvaccinated people who were not hospitalized, and 8–12% for vaccinated individuals.  One challenge that accounts for these wide estimates is that there is still not a universally accepted definition of long COVID.  The US Department of Health and Human Services defines it as “signs, symptoms, and conditions that continue to develop after initial COVID-19 infection and last more than 4 weeks.”  However, even this definition does not include a minimum level of symptom severity or functional impairment, and other current definitions still diverge on symptom duration (4 weeks, 6 weeks, 12 weeks, 3 months, 6 months, or a year since the acute infection).  Additionally there are presently no biomarkers that can help guide the diagnosis. 

Long COVID can occur in all ages, genders, ethnic and racial groups, in people who were previously healthy and fully vaccinated, and in individuals whose acute illness was mild or even asymptomatic.  Manifestations are heterogeneous, multisystemic (the condition can affect any and all organ systems) and can change over time.  But patterns that are both diagnostically and prognostically important can usually be discerned through a careful history-taking process.  Many but not all people with long COVID have pre-existing chronic conditions (including asthma, allergies, attention deficit hyperactivity disorder, musculoskeletal pain, diabetes, poor mental health, insomnia, headaches, chronic fatigue, and frailty), which can exacerbate—and be exacerbated by—it.

Additionally, many long COVID symptoms are non-specific or overlap with those of conditions that commonly coexist (or might be confused) with long COVID, such as chronic musculoskeletal or rheumatological conditions, chronic respiratory conditions, type 2 diabetes, or thyroid disorders.  More challenging still, it is thought that long COVID is frequently misdiagnosed, most commonly as menopause, common migraine, depression, anxiety, or deconditioning.

Clinical investigation and management depend on the duration, nature, severity, and trajectory of symptoms. In people in the first 6 months after acute infection and with more than minimal symptoms, there is some evidence to support a multidisciplinary approach to rehabilitation.  Rehabilitation would normally include pacing strategies (avoiding post-exertional crashes by taking into account the patient’s symptoms on a given day), physiotherapy (and especially breathing exercises), psychological support, cognitive and speech rehabilitation, attention to lifeworld context (such as reasonable adjustments and a phased return to the workplace), olfactory training for anosmia, and dietary advice.  Although exercise has traditionally been a core element of rehabilitation, there is new evidence that unmoderated exercise in long COVID can exacerbate inflammatory and other pathological processes, leading to a worsening of symptoms and delayed recovery. 

Present recommendations for work-up including performing blood tests as appropriate to exclude anemia, renal or thyroid disease, vitamin deficiency (eg, vitamins D and B12), acute phase reactants (eg, C-reactive protein); exclude other causes of fatigue, including sleep disorders and neurological conditions; monitor symptom severity and frequency and pattern of relapses; and keep a patient activity diary to record triggers.  Additional work-up should focus on specific symptoms or signs of body system or organ dysfunction. 

The authors conclude that although there is extensive evidence to support multiple interacting biological mechanisms in the pathogenesis of long COVID, most current clinical management is not derived from these biological mechanisms.  Accelerating the study and implementation of specific treatments targeting these biological mechanisms will be the next area of breakthrough for treatment of those suffering from long COVID.

Mark’s Comments:

I was drawn to this review both because of the topic and also the lead author, who is someone I’ve held in high esteem since I was a resident.  Given the potential numbers of patients who have long COVID, it is imperative that we who practice primary care medicine (and medicine period) continue to both better understand this syndrome and  those who are afflicted with it.   There are many who are claiming “success” with various treatments (including longer term Paxlovid, the vaccine, and various anti-inflammatories and immune modulators).   Unfortunately, it appears that some of these clinicians are taking advantage of this vulnerable population and profiting over their relative desperation to “try anything.”  We owe it to those patients to continue to find ways to support them even when we don’t know the most effective way to treat them.    

Reference:

• Greenhalgh T et al.  Long Covid: a Clinical Update.  Lancet. 17 August 2024: 404(10453):707-724.  Link

From PeerRxMed ( www.PeerRxMed.org )

3)  Elevating Your Kindness Quotient: Take the KQ Challenge

"Kindness is more important than wisdom, and the recognition of this is the beginning of wisdom." — Theodore Isaac Rubin, MD, psychiatrist and author

The gesture was so simple.  It came by text from a colleague:  “Hey Mark, Thank you for these weekly PeerRx nudges and blogs.  They have helped my buddy and I stay connected for the past 4 years.  Just wanted to say thanks.”   That was it – 30 words that likely took less than 15 seconds to compose, and it tenderized my heart for the entire day.

In last week's blog, I shared a story of how a patient calling me “kind” had left me wondering, “What if kindness was one of the most immediately impactful therapies I could provide to those I care for?”  Yes kindness, the powerful force that not only uplifts others but also nourishes our own well-being.  I concluded my blog by encouraging our PeerRx community to take a "KQ Quiz" to gauge your baseline “Kindness Quotient” and promised this week to share some ideas as to how one can increase their KQ.  And now with that recent text, I’m now left wondering, “What if expressing kindness was one of the most important actions I could take every day, within or outside of my work?”

Self-kindness is really the foundation for raising your KQ.  It is crucial for your own well-being, and it is from a place of self-kindness that you will express it to others.  This includes self-forgiveness and compassionate self-talk.  It’s easy to be hard on yourself, especially when things don’t go as planned. But consciously prioritizing and practicing self-kindness will allow you to experience a shift in to a “kindness mindset” over time.    

Once you have established a foundation of self-kindness, other kindness practices flow more naturally.  Giving someone your undivided attention through active listening with the intention of seeking to understand them is sadly, a too rare gift.  Offering a kind word, genuine compliment, or expression of gratitude can quickly lift someone’s spirit.  Performing intentional acts of kindness can be an instant “joy-spreader”, often inspiring others to pay it forward.  Being patient and forgiving when tempted to do otherwise can create a ripple effect of grace and harmony.  Making time for another, even briefly, can be one of the kindest things you can do.  It might mean making a phone call to check in on someone, offering to help with a task, or simply sitting with them. 

So as you can see, increasing our KQ doesn’t require sweeping changes or elaborate plans.  It starts with small, intentional actions that when repeated daily, can lead to a profound shift in how we experience the world and how others experience us.  As the ancient Greek storyteller Aesop reminds us, "No act of kindness, no matter how small, is ever wasted."  So consider accepting my 21-day “Kindness Challenge” by choosing to perform at least one intentional act of kindness every day for the next 3 weeks and noticing the impact on you and others.  Then share what you experience with your PeerRx partner or another colleague.  In doing so, you may find that kindness starts to become not just something you do, but who you are.  And that might just change your life – for the even better.    

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org