COVID NEXT: Children, Sequelae, Variant Whack-a-Mole and the Brilliance of Masks

COVID’s evil twin, Long COVID, can be as dangerous — and potentially even more debilitating — as the original infection. “Post-acute sequelae of SARS-CoV-2,” or PASC as it is officially known, is a suite of symptoms that afflicts as many as a third of all patients with profound fatigue, dizziness and most frightening of all, brain fog. Even a mild case of COVID can affect cognition.

Sequelae are the second act of an illness, the result of damage left in a pathogen’s wake. If you think of an infection as an earthquake, then sequelae are the tsunami that follows. And Long COVID is a tsunami poised to swamp us all.

The stats are terrifying. As of early August 2021 more than 200 million people around the world have had COVID (36 million in the US) and 4.3 million have died (627,000 in the US). Those are likely low-ball figures. Not every case is diagnosed, nor every death recorded.

Missing from those astounding tallies are the millions who have survived but have yet to fully recover. Their lives — and those of their families — have been derailed.

Less than two years into the pandemic, we are playing viral whack-a-mole with a Greek alphabet-full of scary variants. Delta is so infectious that even those who are vaccinated can catch it and spread it. For the most part vaccines prevent serious, life-threatening illness, but people are still getting sick. And even a mild case of COVID can lead to Long COVID.

Just how long can Long COVID go on. Weeks? Yes. Months? For many. Years? For some. Decades? Stay tuned.

Those most at risk, of course, are the unvaccinated, including nearly 50 million children under 12 in the US for whom vaccines have yet to be approved.

The risk isn’t only about catching COVID, although in the past week nearly 100,000 kids did just that, filling up children’s hospitals mostly in southern states where where vaccination rates have been low, including Texas, Louisiana, Arkansas, Missouri, Mississippi and Florida. In Dallas, a city of 1.2 million people in a state where the governor has outlawed mask mandates, the situation has been framed in the starkest of terms: “…If your child’s in a car wreck, if your child has a congenital heart defect or something and needs an ICU bed, or more likely if they have COVID and need an ICU bed, we don’t have one. Your child will wait for another child to die.”

And Long COVID lurks in the wings.

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Research on Long COVID is happening in real time as the pandemic explodes, so no one knows for sure how prevalent sequelae are in children. There have only been a few, small studies. But given the growing number of cases, even a small percentage would still translate into a lot of kids.

Imagine being six years old, trying to learn how to read with brain fog? Or being a teenager battling exhaustion while slogging through college entrance exams? Problems snowball. The six year old stumbles in school and loses self-confidence. The teenager’s scores are too low to get into the university she had set her sights on. Young children act out. Teens battle depression. The trajectories of young lives knocked off course.

From “the missing kindergartners” to missed social interactions, COVID has already come at a high cost for children. Also their parents — moms in particular — who have had to quit jobs to stay home to take care of them. Families have been struggling for the last year and a half under enormous emotional and financial strain.

So almost everybody is rooting for a return to in-person school. The very good news is that even with the super-contagious Delta variant it is still possible to do so safely. According to a recent study that looked at 100 school districts and 14 charter schools in North Carolina (nearly 1.3 million students and 160,000 staff), masking works, even with minimal social distancing. But everyone has to wear a mask or it doesn’t work, says study co-author Dr. Danny Benjamin: “Having a voluntary mask policy is like having a no-peeing section in a pool or no-smoking section on a plane. That’s absurd.”

Equally absurd is to turn masks into a symbol of government oppression. Yet here we are, with a handful of state governors and far-right politicians conflating “liberty” with “mask choice.” In California, one parent was so enraged at seeing his daughter wearing a mask when he picked her up from school that he physically attacked the school’s principal and a teacher, sending the latter to the hospital. Violence, it turns out, is another sequela of COVID + fake news.

At stake: not only protecting children’s health in the here and now (and keeping them from needing hospital ICUs), but also their health in the future. Long COVID could blight a generation.

It wouldn’t be the first time this has happened.

SEQUELAE
COVID is far from the first disease to pack an encore punch. In fact, disease sequelae could be more the rule rather than than the exception. The time lag between infection and sequelae — which can be weeks, months, or even years — can make it difficult to connect the dots. It is easier see patterns when a disease affects a large number of people at the same time.

• The polio epidemic of the early 20th century affected millions of people, including many children. But the symptoms of Post-Polio Syndrome (PPS), which include muscle weakness, joint pain, brain fog, and difficulty breathing and swallowing, can take thirty or forty years to manifest. No one saw it coming. After the heroics of iron lungs, intense physical therapy and ultimately a vaccine (which is still on the CDC list of recommended childhood vaccines), people thought polio had been vanquished, a problem no more. But decades later, when a significant number of survivors began to experience a devastating collection of symptoms, medical researchers began to investigate. PPS is still a mystery, but the prevailing theory is that motor neurons that survived the initial viral assault did double duty to make up for neurons that were lost. Given enough time these heroic, exhausted neurons begin to die off en masse, causing PPS, the legacy of a long-gone virus. Some have speculated that West Nile Virus, which can inflict the same kind of neuronal damage as polio, may eventually lead to a Post-West Nile Syndrome. Time will tell.
• The 1918 “Spanish” Flu — the pandemic against which all other pandemics are judged, — swept across the world infecting an estimated half billion people and killing anywhere from 20 to 50 million in two years. More than a century later historians and medical researchers continue to sift through archives for clues of sequelae. Letters written by convalescents are filled with references to muscle weakness and “nervous complications.” Epidemiological data suggest that compared to older siblings, children born during the height of the pandemic — or even still in their mothers’ wombs — were at a significantly greater risk of developing heart disease and diabetes many decades later. Non-pandemic strains of flu can also lead to “complications,” including myocarditis (inflammation of the heart), encephalitis (inflammation of the brain), muscle weakness and organ failure.
• Sequelae can take many forms. Strep infections in children, for example, have been linked to symptoms of ADHD. Researchers suspect an auto-immune component. Likewise, paralysis from Guillain-Barré syndrome (GBS) is the result of an auto-immune attack on the peripheral nervous system. The trigger is thought to be an infection several weeks prior. There is a long list of suspects, too, including West Nile, Zika, Influenza, COVID-19, and campylobacter bacteria from eating undercooked poultry. A stomach bug may also play a role in some cases of Parkinson’s.
• Myalgic Encephalomyelitis / Chronic Fatigue Syndrome (ME / CFS) is a catch-all for a suite of sequelae without an identified cause. The debilitating condition has yet to be linked to a specific pathogen (or pathogens), so risk factors are hard to pin down. Symptoms include exhaustion, brain fog, muscle weakness, joint pain and dizziness. ME / CFS primarily affects middle-aged adults, but can strike anyone, including children. According to the CDC, as many as 2.5 million Americans have it, though only roughly 10% have been diagnosed.

IS LONG COVID REALLY ME / CFS?
The overlap in symptoms between Long COVID and ME / CFS is hard to miss. Some scientists are starting to say they are indeed one and the same. Although other pathogens no doubt are linked to ME / CFS, it is difficult to connect the dots given how long it can take to confirm a symptoms-based diagnosis. The rapid rise in the number of Long COVID cases makes it easier to spot the pattern.

The etiology (mechanics) of how SARS-CoV-2 (the virus that causes COVID) leads to Long COVID, is still full of unknowns. Scientists are beginning to tease apart clues in the structure of the virus, specifically its constantly evolving, troublesome spike protein. The spike functions as a kind of universal key designed to break into to almost any kind of cell. This is why COVID is much more than a respiratory illness. It can target almost any organ, including the heart, kidneys and brain.

Research suggests that the spike (key) doesn’t even need to bring the rest of the virus into the brain to cause problems (this is probably true for other organs as well). Simply tickling a cell’s “lock” can be enough to set off a “cytokine storm,” an immune response so ferociously excessive it can itself inflict considerable harm.

Long COVID may turn out to be an auto-immune condition, or perhaps the body’s attempt to recalibrate after a viral assault. Or, as some early research suggests, COVID could “re-awaken” the Epstein-Barr Virus (EBV), which goes dormant after infection, but stays in the body forever. In a recent study in the US, the vast majority of long-haulers showed evidence of EBV reactivation.

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Separate from Long COVID is MIS-C (Multisystem Inflammatory Syndrome in Children), which has already been linked as sequelae to the virus. The oddly appropriate acronym covers a range of horrifying symptoms: fever, pain and organ inflammation (heart, lungs, kidneys, skin, eyes, intestinal tract). To date, about 4,400 cases have been diagnosed in the US. Scientists are starting to tease apart the mechanics of the syndrome, identifying malfunctioning immune cells as a key component.

NUMBERS
With the Delta variant driving a steep and rapid increase in case numbers here in the US and across the world, it is only a matter of time before the number of Long COVID case start to rise dramatically as well.

At risk for COVID in US, so also at risk for Long COVID:

• 50 million children under 12 who are still ineligible for vaccine
• 14 million teenagers who have yet to be vaccinated
• 7 million immunocompromised adults
• Tens of millions of adults who have chosen not to get vaccinated

Yet those who have been vaccinated aren’t necessarily in the clear, either. ”Breakthrough infections” happen. Symptoms are typically milder, or at least not serious enough to require hospitalization, but a mild case of COVID can still lead to Long COVID.

So we really are all in this together. Still.

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According to the Disability Justice Initiative at the Center of American Progress, if even a small percentage of long haulers apply for federal disability services, an already underfunded system could collapse: an economic sequela.

Whether measured in blighted lives, lost lives, lost time, shredded finances or heartache, the costs are enormous.

Masks are cheap. Vaccines are free. And unlike an earthquake, we can do something about COVID. We can slow the Long COVID tsunami.

ALMOST BACK TO SQUARE ONE (WITH A MUTANT TWIST)
The plague of political posturing and fake news keeps us all in danger:

• With each new infection, the COVID virus mutates. Most mutations won’t present a threat. Some will.
• The Delta variant is considerably more contagious than COVID Classic, meaning each infected person can spread the disease to several more people.
• Delta can infect those who are vaccinated, generating enough virus so that they become spreaders, even if they don’t get sick.
• Everyone, vaccinated or unvaccinated, can spread Delta.
• Those who are unvaccinated tend to get sicker, but everyone who gets COVID runs the risk of developing Long COVID.
• Scientists do not yet know why some people develop Long COVID and other don’t.

The one shred of encouraging news is that vaccination has helped a subset of long haulers, reducing the severity of some of their symptoms.

Which takes us back to masks, a physical barrier (a wall) that blocks the COVID virus from gaining entry into a host.

No host.
No infection.
No replication.
No mutation.
No sequelae.

Also, you can see a mask. There is simply no way to know by looking who has been vaccinated and who has not. More to the point, there is no way to know who could be spreading disease.

Wearing a mask is basic, common sense, ground-zero self-protection. It also signals to others a reduced risk. Even if a mask-wearer is infectious, a mask blunts the ability of the virus to go airborne. Add in social distancing and the risk of catching COVID drops even further.

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In Florida, a governor with a degree in law, not medicine, is using his bully pulpit to sing the praises of free infusions of monoclonal antibodies to treat mild cases of COVID (the same treatment given to a former President). As an emergency measure to help alleviate the burden on overwhelmed hospitals running out of ICU beds, it has some merit. But it is not free. The treatments are paid for by federal government (which means you and me) at $1,500 a pop. It also requires sick people to schedule an appointment online and since this is an outpatient procedure, arrange transport to and from a medical center. The treatment is effective, but also no guarantee against later developing Long COVID.

The only surefire way to keep from getting Long COVID is not to get COVID in the first place.

Wearing a mask says you give a damn about the future. Yours. And everyone else’s, too.