Bonnie Raitt performing Angel From Montgomery at the 2022 Billboard Women In Music Awards.  Saw her on June 21st at the Beacon Theater in NYC.  Could not find a half decent YouTube clip from show itself.  Suffice it to say, she was amazing. 

Playing the Long Game

Been awhile since posting.  This is in part because there is not a ton to update you on.  Unless, that is, you want me to simply chat about recent concert setlists, how to set up your garden, or some of the sickening news occurring around the globe.

Today’s posting is to address an excellent question raised in response to the last post. The question was whether vaccination would help prevent children from getting long covid related symptoms.  There is not a ton out there with children in particular, but will try to provide some insight into what is known along with links to the studies themselves.  As a bonus plan, will give you a very quick monkeypox overview.

For those wondering how I spent my summer vacation….enjoyed a long road trip with my family down East Coast.  A great week with my youngest daughter in the Smokey Mountains (hence today’s cover pic).  And a ton of shows.  Some highlights as today’s videos.  I will warn you again later regarding the final video.  The comedic video is definitely NSFW.  And if you tend to get offended by comics in general, spare yourself the elevated blood pressure and just don’t click on it.

Long Covid

Today’s discussion will set out to provide you with an overview of what “long Covid” is, how common it is, and the degree to which vaccinations will prevent it from occurring.

What is Long Covid?

The very simple answer is symptoms extending beyond the couple of weeks attributed to acute infection with the virus causing Covid.

However, defining what exactly “Long Covid” includes is problematic in and of itself.  This lack of definition leads to a variety of different interpretations among those conducting research on the topic, as well making it more difficult to compare the data between studies.

Problem #1 is that there is no definition as to how long after contracting Covid we should begin calling symptoms “Long Covid.” Generally speaking, studies have considered the minimum time frame to be considered “long covid related” are symptoms present at least 4 weeks post infection.  Whether that is sufficient or too short can be debated.

Problem #2 is that there is no definition as to what symptoms should be including when discussing or studying “Long Covid.”  Different studies include completely different lists of symptoms.  The sample list below is from the CDC’s Morbidity and Mortality Weekly Report (which used the 4 week mark as defining long Covid):

Fatigue Change in smell or taste Shortness of breath
Cough Headache Problems sleeping
Joint or muscle pain Cognitive dysfunction Chest pain
Change in mood Post-exertional malaise Stomach pain
Hair loss Diarrhea Sore throat
Fever or chills Palpitations Nausea/vomiting
“Other”

A true cornucopia of entertainment.  For the sake of completeness, the study for which the above symptoms were considered did not find all of them to be statistically significant.  In plain speak, just because it is listed does not mean that it has been shown to be due to Covid in those that suffer with that symptom.  Those found to be statistically significant in the study, conducted on 1500 people at a 95% confidence level, were fatigue, change in smell or taste, shortness of breath, cough, problems sleeping, joint or muscle pain, chest pain, change in mood, and sore throat.  Here is the kicker of the statically significant symptoms…..those who had Covid were less likely to report change in mood.  Don’t ask why.  We could philosophize on that all day.  Would love to get a Daniel Tosh 20 seconds on the clock for that topic.

As an interesting aside, neither this study nor any other I went through mentioned sexual complications.  See, there is a silver lining in everything.  Considered a long covid “that’s what she said” joke here cause it would have fit….but I refrained….or did I?

Jack Johnson performing Upside Down at Jones Beach on June 22nd

How Common Is Long Covid?

Pretty common.

Not surprisingly, there has been far more study on this topic in adults as compared with children.  This is largely because adults tend to suffer from more significant symptoms.  Among adults with milder disease, the estimates are that 1-in-3 individuals suffer from long Covid.  Those with more severe disease (i.e.: hospitalized) tend to suffer from long Covid at more than twice that rate.

If you are interested in some further reading on this topic in adults, feel free to peruse the following:

Hirschtick, et al.  Clinical Infectious Diseases.  Volume 73. Issue 11. December 2021. Pages 2055–2064.

Addressing the frequency of long Covid in children and adolescents has begun to gather more attention.  Many of the early studies had results that indicated there should be some concern for long Covid in the age group.  This included among those with very mild or no acute symptoms.  The issue with these early studies was primarily their sample size which ranged from a few dozen patients to several hundred.  A nice review article of many of these earlier studies was published at the end of 2021 by Zimmermann, et al.  If you want to check a few examples of these earlier studies, the links below will take you there:

Trapani, et al.  Italian Journal of Pediatrics.  Volume 48.  Article 83.  June 2022.

Pooya, et al. World Journal of Pediatrics. Volume 17.  September 2021.  Pages 495–499.

Ashkenazi-Hoffnung, et al. Pediatric Infect Dis J.  Volume 40, Issue 12. December 2021, Pages e509-e511.

Based on the results of the early studies raising the specter of concern for children and adolescents, a call out was made for larger studies.  Some of these studies have emerged during 2022.  The first two discussed below were both conducted in Denmark.

The first study, by Kikkenborg-Berg, et al, included 24,315 adolescents with positive tests along with 97,257 controls (i.e.: those without positive tests).  This study concluded that those with positive tests had more long-lasting symptoms and required and increased quantity of sick leave.  Nearly half (47.8%) of the case group reported new symptoms present 8 weeks post infection.  The control group had a worse quality of life.  Yep.  That’s twice now.

There are a lot of limitations with this study.  These include that it was based on questionnaires with a very long list of symptoms, a very low response rate to those questionnaires (about ¼ folks responded), potential bias as to whom responded based on demographic factors, and that different questionnaires were given to case and control groups.

The second study, conducted by Borch et al, included 37,522 case and 78,037 control subjects.  Both children and adolescents were among the subjects of this study.  They too found a substantial number of cases with reported symptoms (28%).  However, they did something prior study did not do.  Specifically, they looked for same parameters in the control group in the same manner as the case group (i.e.: same questionnaires for all).  They also reported their data differently.  Rather than stating that X% of cases had a symptoms and that it was statistically significant, they reported a residual percentage.  By subtracting out the percentage of controls with symptoms, they found a residual percentage of 0.8%.  This would mean that the rate of long Covid related symptoms in this age group may be closer to 1-in-100 in reality.  And yes, you could look at the numbers in the first study and try to do those calculations on your own.

There is an ongoing study, known as the CLoCK study, in the UK.  Preliminary results were released which stated that 14% of those positive for Covid had long Covid symptoms relative to controls at a 15-week endpoint.  This study used questionnaires as well.  Of the 220,000 that were sent out, only 17,000 resulted in a response.  It will be interesting to see the data in all its glory once the study is completed.

So is Long Covid a Concern in Kids?

I will wager that the answer is yes on this one.  Even if it is 1% of the time, when you assume that every child and adolescent will get Covid, this is a ton of kids.  We can debate how significant these symptoms are, how long they persist, and a litany of other aspects another time.  And yes, there are other viruses such as EBV that can render a kid miserable for quite some time that we have known for awhile.  So let us take this perspective going forward for purpose of discussion:  long covid exists, roughly 1% get it, and it causes some level of discomfort for that 1%.  With that perspective in mind…..Can we help prevent this outcome?  At what cost?

Dead and Company June 24th and 25th at Wrigley Field, Chicago.  Had to get my fix and could not make any other East Coast shows.  Brown Eyed Women on the 24th may well have been show highlight.  Not a typical tune to consider for such, but man did Mayer kill it.  First set opener, Scarlet Begonias from the 25th.  No subsequent Fire on the Mountain until late in second set.  If you have any clue what I am talking about you are either a Deadhead or married to one.  That comment is for you Jamie.  And Lynn (thanks for letting Scott join me, broken ankle and all).

Does Vaccination Against Covid Prevent Long Covid?

A study by Antonelli, et al in Lancet looked at data from over 2 million people that were interacting with a Covid Symptom Tracking app in the UK and had received at least one dose of  vaccine against Covid.  Most of the end points in the study were consistent with prior studies regarding Covid vaccines.  Specifically, they contracted Covid less often, got less sick, and that the older and obese members of society fared worse.  To the point of our discussion today, of those that received two doses of vaccine (971,504 of the subjects), 2370 contracted Covid nonetheless.  The rate of long Covid in this group was halved.

In another study, conducted by Taquet, Dercon, and Harrison in Brain, Behavior, and Immunity,  10,000 infections after vaccination against Covid (aka: breakthrough infections) were assessed.  The study concluded that vaccination does not appear to be protective against several previously documented outcomes of COVID-19 such as long-COVID features, arrhythmia, joint pain, type 2 diabetes, liver disease, sleep disorders, and mood and anxiety disorders.  They also came to the same well known conclusions that vaccination provided a significantly lower risk of respiratory failure, ICU admission, intubation/ventilation, hypoxemia, oxygen requirement, hypercoagulopathy/venous thromboembolism, and seizures.

Overall, not the most convincing data regarding vaccines protecting against long Covid in adults in the same manner it protects from “severe disease.”  I did not find any study addressing the question in children specifically.  It is worth noting that there are less cases of Covid among those vaccinated.  This represents the minimum efficacy of the vaccines for preventing long Covid.  The current vaccines are not nearly as protective against current strains in this regard, but they do offer some.  You cannot get long Covid if you do not get Covid.  These studies were addressing breakthrough infections, not baseline societal numbers.

Can You Get Long Covid From the Vaccine?

Possibly? I could provide theoretical methods involving inflammatory responses in certain predisposed individuals based on their specific responses to an antigen challenge.  That being said, I did not find any true studies to address this question.  There was a news article in Science last January though that stated there are anecdotal reports and that the issue is a matter of ongoing study.  The authors did mention that the concern at this time appears to be very rare and thus would not be a reason to forego vaccination.

Rage Against the Machine at MSG on August 9th.  OMG.  Whole show above.

Can the Vaccine Help If You Already Have Long Covid?

This was not part of what I intended to look for, but since I stumbled upon it, I figured it was worth sharing briefly.  The answer is that it may actually help some.  If this topic floats your boat, click on the following links to learn more:

Sivan, et al.  British Medical Journal.  Volume 377. May 2022. 

Ayoubkhani, et al.  British Medical Journal. Volume 377. May 2022.

Any Other Guidance, Doc?

Most of you have the same fundamental question…..should I vaccinate my child against Covid?

My concerns for risk to a child receiving the vaccine at this point are minimal.  Nothing is zero risk, but this would be pretty close by most people’s standards.

Not carrying risk, and aggressively recommending something are different issues.

What are the benefits?  For starters, there is less likelihood they will contract Covid.  The degree of the protection is less with current strains, but it does offer protection.  When the newer versions come out in the next month or two, this degree of protection will hopefully rise significantly.  Less kids with Covid also means less family members with Covid.  Less adult family members with Covid, less adults with severe disease.  Severe disease continues to be rare in children.  Again, rare is not zero. On a societal level, the less circulating Covid, the less mutations we have to roll the dice that could render some emerging variant super deadly.

What is the downside?  The vaccines do not appear to offer marked protection from getting Covid beyond six months at this time.  Signing a two-year-old up for an injection every six months for a disease that does not significantly affect them seems a bit aggressive.  Should ongoing study on long Covid demonstrate a higher percentage of children suffering with it AND that the vaccine prevents that outcome, then this would warrant revisiting.

And that is all I have to say about that. 

Bought tickets for Chris Rock and Kevin Hart at MSG July 23rd.  Got the mega bonus plan of Dave Chappelle!!!!  This is a most definite NSFW video.  You were warned.  

Monkeypox

Here is your super quick lesson in Monkeypox.

It’s caused by a pox virus.  There are four classes of pox virus.  This one is related to smallpox.  Smallpox kills people real well.  Monkeypox does not.  Molluscum Contagiousum is also caused by a pox virus for those curious at home.  It is in a different class of pox virus.  Fun fact for the curious #2, chickenpox is not caused by a pox virus.  It is a herpes virus.

Contracting monkeypox generally involves close contact with some with monkeypox.  At this time it is considered primarily as a sexually transmitted disease.  Yes, you can get it from contact with shared objects, but this is far less likely.  And I am referring to towels and such like the CDC link below discusses.  Shame on you.

With proper targeted adult vaccination campaigns and basic precautions, this should not become an issue in children.

On the topic of vaccines for monkeypox….if they could actually make a completely safe smallpox vaccine, it would cover against monkeypox as well.  Bonus plan is it would save us should some foreign leader decide to unleash it.  The only known stockpiles outside the US happen to be in Russia.  Yep.  Just planted that seed for you to ponder.

Want to read more on monkeypox?  Try Wikipedia.  Or the CDC.

I am not entertaining this topic any further at this time.  There are currently three cases reported in children.  No real data.  Just speculation they get to blame an adult in their home.

A couple of more shows from the summer to date.  Phish performing Chalkdust Torture on July 26th at Jones Beach.  And lastly, Gov’t Mule covering the Allman Brother’s Come and Go Blues at the Paramount Theater on August 7th.  

Post authored by Jason Halegoua PhD, MD, MBA, FAAP.  Jason is the founder of Peds First Pediatrics in 2009, and has been a practicing general pediatrician since completing residency at Schneider Children’s Hospital in 2004.  In addition to earning his medical degree from the Medical College of Pennsylvania, Jason earned a PhD in Molecular Pathobiology for his work contributing to the understanding of the genetic regulation of immune responses to murine leukemia viruses from Hahnemann University in Philadelphia and an MBA in Finance from Hofstra University.