The Checkup With Dr. Wen: How to think about the risk of long covid

Thursday, March 31, 2022

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Guidance on navigating the pandemic and other public health challenges

By Leana S. Wen
Opinions columnist

Since last spring, I've been writing that vaccinated people can choose to return to their pre-pandemic activities. Most individuals who are fully vaccinated and boosted have a very low chance of severe illness due to covid-19, and many have decided that the benefit of resuming much or all of the activities they love is worth the risk of contracting the coronavirus.

Not everyone agrees with this assessment. Some readers have raised the specific concern of long-haul covid. "Much of your regular commentary has been about living with covid in society and taking some precautions if necessary," wrote Lauren from California. "However, I don't see you talking about long covid and the ramifications of lifting precautions when this is looming."

Christina from Massachusetts agrees. "I am staying masked, being cautious and having people do rapid tests before they can unmask in my house. I don't understand the focus on hospitalizations and the rush to unmask when so little is unknown about long covid, and it appears even vaccinated people with no immunosuppression are at risk. Long covid may mean a life will be changed forever."

I understand the concern that Lauren and Christina are expressing. I've seen patients with fatigue, brain fog, shortness of breath and severe headaches months after their recovery from covid-19. Some were in the hospital and gravely ill when they had covid. Others were only mildly symptomatic. Some had underlying diseases. Others were previously healthy.

A growing number of studies also show an association between having had the coronavirus and increased risk of heart disease and diabetes, as well as changes to the brain's structure.

It's clear that long covid is a real concern. Though the exact mechanism that causes the condition is unknown, other viruses are also associated with inflammatory changes that can cause chronic, debilitating diseases.

Gauging the risk of long covid also requires an understanding of how likely it is that people will contract the coronavirus. A new Monmouth University poll suggests about 52 percent of Americans self-reported that they have already had the coronavirus, up from 40 percent in late January. This is testament to how contagious the omicron variant is, as well as the new BA.2 subvariant, which is even more transmissible.

Thankfully, vaccination reduces the likelihood of contracting the coronavirus in the first place. Studies also show that for the vaccinated who are infected, the risk of long covid is halved.

The question I would pose for the vaccinated is this: What is the price you are willing to pay to avoid long covid? Your risk has already decreased because of vaccination. How much more do you want to reduce your risk, and what are you willing to give up to do so?

Some people will say they want to avoid long covid at all costs. In that case, Christina's plan of masking in public settings and asking visitors to test prior to unmasking indoors is sensible. Others accept the risk of long covid, just as they do the potential of long-term symptoms from other viruses, and do not wish to forgo activities or to continue masking.

I think both are reasonable decisions. In the meantime, we need far more research into the long-haul symptoms associated with covid-19, including the likelihood of long covid with reinfection and effective treatments for those afflicted.

I addressed long covid and other topics in a Q&A with readers on Wednesday. Check out a transcript of the chat here.

My latest column

How allowing a second booster shot signals a shift in pandemic guidance

Opinion ● By Leana S. Wen ● Read more »

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"With so many people self-testing and the elimination of contact tracers in most areas, how do we have an accurate count of covid-19 cases? People I have spoken with who test positive with a home test say they are not reporting it to any government agency." — Marjorie from New York

The number of reported covid-19 cases is a substantial undercount. It has been that way during the entire pandemic in the United States. Initially, and during some surges — including the omicron surge — this was because of a lack of testing. More recently, it's also because of home tests that are not reported to local health departments. In addition, many health departments are switching to weekly reporting, so increases might not be reflected in real time.

This is why I support the surveillance efforts taken by the Centers for Disease Control and Prevention, including wastewater sampling. People with the coronavirus shed it in their feces, and studies have shown that virus levels in community wastewater rise days before an increase in positive tests. This type of early warning signal is essential going forward to mobilize resources ahead of future covid-19 surges.

"Since the pandemic began, my wife and I have driven a car only with each other. Many of our friends have returned to the practice of carpooling to events and activities. We are in our early 60s, fully vaccinated and boosted, and generally in good health. What are best practices around carpooling?" — Don from North Carolina

Let me ask a question back to you: What activities have you already resumed? For example, if you are already getting together with your friends anyway, indoors and without masks, then there's not much additional risk to carpooling with them to the same destination.

On the other hand, if you are still socializing outdoors only, or requiring tests before unmasking indoors, then you might consider taking additional precautions when in the car with others. The safest thing to do is for everyone to wear an N95 or equivalent (KN95, KF94) mask. Rolling down the windows to improve ventilation can help, too.

"My son and daughter-in-law want to visit us this summer from California. Both my husband and I are in our mid-70s, vaccinated and boosted, and in good health, as is my son. My daughter-in-law is unvaccinated and part of the 'California wellness group.' We would love to see them but are concerned about risks. What is your medical and 'kindly human' opinion on how to handle this?" — Susan from New Jersey

I can certainly understand the desire to see your family and also your wish to do so as safely as possible.

Is your daughter-in-law willing to take a test before seeing you? Even better is if she and her family can reduce their risk exposure for three days prior to their flight and then take a rapid test before being with you and your husband. If they do this, their risk to you will be very low, and you can host them in your home and socialize with them indoors without the need for masks.

The Post has also compiled Q&As from my previous newsletters. You can read them here.

What I'm reading

A new National Institutes of Health study published in JAMA found that the number of alcohol-related deaths, including from liver disease and alcohol-related accidents, rose to more than 99,000 in 2020, up from fewer than 79,000 the year before. This represents an increase of 25 percent in one year. Rates increased across all age groups, with the largest rises occurring in people between 35 and 44 (up nearly 40 percent) and 25 to 34 years old (up 37 percent). For people under 65, alcohol-related deaths exceeded the number of deaths from covid-19 in 2020. This and similar studies underscore the need to consider the impacts of the pandemic far beyond deaths from the virus alone.

David Wallace-Wells presented a fascinating analysis in New York magazine in which he considers excess mortality to be the true measure of the lives lost due to covid-19. He writes, "Perhaps most striking, given both self-flagellating American narratives about the pandemic and current events elsewhere on the globe, is that the worst-hit large country in the world was not the U.S., which registered the most official deaths of any country but ranks 47th in per capita excess mortality, or Britain, which ranks 85th, or even India, which ranks 36th." In fact, countries with the highest excess mortality are Bulgaria, Serbia, North Macedonia and Russia, followed by Lithuania, Bosnia, Belarus, Georgia, Romania and Sudan.

A group of virologists wrote an op-ed for the New York Times in which they speculate that "SARS-COV-2 will continue to cause new epidemics, but they will increasingly be driven by the ability to skirt the immune system. In this sense, the future may look something like the seasonal flu, where new variants cause waves of cases each year." In that case, the vaccines will need to be regularly updated, like the flu vaccine, and we as a society need to learn to live with covid-19 just as we do with influenza.