❦ On that 700-day cough... It’s a new thing, but it’s only reserved for supermarkets and offices. And pharmacies and hospitals. Oh, and your living-room. But apart from that, it’s not exactly a deal-breaker. I mean, c’mon. They put up with way worse in the 1900s. © 2024 C19.Life ❂

❦ If you are letting yourself get infected and taking no precautions against passing it on, you are not a passive bystander for your next infection. You’ve participated in creating it. ❂ © 2024 Dr. Noor Bari, Emergency Medicine .

❦ ‘In this population of healthy young adult US Marines with mostly either asymptomatic or mild acute COVID-19, one fourth reported physical , cognitive , or psychiatric long-term sequelae of infection. The Marines affected with PASC [Post-Acute Sequelae of COVID-19 / Post-COVID-19 Complications / ‘Long Covid’] showed evidence of long-term decrease in functional performance suggesting that SARS-CoV-2 infection may negatively affect health for a significant proportion of young adults .’ ❂ ‘Among the 899 participants, 88.8% had a SARS-CoV-2 infection. Almost a quarter (24.7%) of these individuals had at least one COVID-19 symptom that lasted for at least 4 weeks meeting the a priori definition of PASC established for this study. Among those with PASC, 10 had no acute SARS-CoV-2 symptoms after PCR-confirmed infection suggesting that PASC can occur among asymptomatic individuals. Many participants reported that lingering symptoms impaired their productivity at work, caused them to miss work, and/or limited their ability to perform normal duty/activities. Marines with PASC had significantly decreased physical fitness test scores up to approximately one year post-infection with a three-mile run time that averaged in the 65th percentile of the reference cohort. [ PASC was associated with a significantly increased 3-mile run time on the standard Marine fitness test. PASC participants ran 25.1 seconds slower than a pre-pandemic reference cohort composed of 22,612 Marine recruits from 2016 to 2019. A three-mile run evaluates aerobic exercise , overhead lifting of an ammunition can and pull-ups evaluate strength , and shooting a rifle evaluates fine-motor skills .] Scores for events evaluating upper body (pull-ups, crunches, and ammo-can lift) were not significantly reduced by PASC; however, overall physical fitness scores were reduced. ‘The poorer run times and overall scores among PASC participants are indicative of on-going functional effects.’ Standardized health-based assessments for somatization, depression, and anxiety further highlighted the detrimental health effects of PASC. Almost 10% of participants with PASC had PHQ-8 scores ≥10. Increased somatization * has been associated with increased stress, depression, and problems with emotions. * [ Somatization / Somatisation = Medical symptoms caused by psychological stress.] Additionally, PASC participants had higher GAD-7 scores suggesting increased anxiety in a population with unique inherent occupational stressors associated with higher rates of anxiety, depression, and post-traumatic stress disorder. ‘Increased severity of anxiety among those with PASC, combined with greater rates of mental health disorders in general, could portend an ominous combination and should be closely followed.’ Like others, we identified cardiopulmonary symptoms as some of the most prevalent. The high prevalence of symptoms like shortness of breath, difficulty breathing, cough, and fatigue is particularly notable when combined with decreased objective measures of aerobic performance such as running. These results suggest pathology in the cardiopulmonary system. In contrast we observed no reduction in scores assessing strength and marksmanship suggesting the lack of detectable pathology in the neuro-musculoskeletal system. We have previously found in this same cohort that SARS-CoV-2 infection causes prolonged dysregulation of immune cell epigenetic patterns like auto-immune diseases. Based on the reported PASC symptoms, the potential current and future public health implications in this population could be substantial. ‘Chronic health complications from PASC, especially in a young and previously healthy population with a long life expectancy, could decrease work productivity and increase healthcare costs.’ Significant changes in the Years-of-Life lived with a disability can disproportionally increase disability-adjusted life-years, and should be considered when allocating resources and designing policy.’ ❂ 📖 (23 Oct 2024 ~ The Lancet: Regional Health/America) Clinical and functional assessment of SARS-CoV-2 sequelae among young marines – a panel study ➤ © 2024 The Lancet .

❦ If parents, and politicians and teachers, and healthcare workers and public health bodies wanted things to change, all they need do is read . It’s all there. But they don’t. They won’t. And they insist on their scientific flat-earthing – hand-sanitiser for airborne disease – because they want the world to be flat. So let them walk off the edge of the world. [ Caveat: The earth is not flat, and doing nothing will not flatten the curve – but walk far enough, and you are likely to fall off a cliff.] © 2024 C19.Life ❂

‘In those school-rooms where ventilation is imperfect and the air impure, six sevenths of the money expended to educate a child is wasted.’ ❂ The Ventilation and Warming of School Buildings (1887) By Gilbert B. Morrison Published by D. Appleton and Company, New York. 1887. Accessed 10 Apr 2024 Preface (p.xxii) ❦ ‘I am fully convinced that people are prematurely dying by thousands simply from a lack of correct and positive convictions concerning impure air; for, when the true nature of a danger is fully appreciated, the requisite means to avert it will generally be found.’ ❂ Chapter II: The Effects Of Breathing Impure Air (pp.20-23) ❦ ‘Impure air is also believed by the best authorities to be one of the principal causes of epidemics. Dr. Carpenter, than whom there is no abler authority, says: “It is impossible for anyone who carefully examines the evidence to hesitate for a moment in the conclusion that the fatality of epidemics is almost invariably in precise proportion to the degree in which an impure atmosphere has been habitually respired.” The Board of Health of New York conclude that forty per cent of all deaths are caused by breathing impure air. In view of such alarming facts, this same board declares: “Viewing the causes of preventable diseases, and their fatal results, we unhesitatingly state that the first sanitary want in New York and Brooklyn is ventilation .” Direct experiment proves that the air in our school-rooms is impure in almost all cases, and in a majority of them to a degree far beyond the danger line. In view of these facts, and the results as proved by the authorities above cited, why is it regarded by the public with such indifference? When a school-house is blown down by a hurricane, killing and maiming a score of children, it is justly regarded as a great calamity; a vacation is given to quiet the excited fears of parents and children; investigating committees are appointed to locate the responsibility, and the faces of the whole populace are blanched with apprehension. Why is this? Why does the intelligent parent send his child to a school-room poorly ventilated and crowded with children, some of whom are breathing into a stagnant air the germs of disease and death, while others, from unwashed bodies, are delivering into it their deadly emanations, and all without a protest on the part of those even who provide proper hygienic conditions at home? It is because the effects of the one are immediate, occupy little time, the number killed can be actually counted, and the exact magnitude of the calamity estimated all at once. In the other case the process is slower, but of far greater extent; the actual results are by the general public less definitely known, and custom and attention to other matters divert the attention, and the deadly destruction of the innocents by impure air goes on silently, constantly, and powerfully. While noisy demonstrations like that of the cyclone attract attention, and inspire fear and terror, it is in the silent forces that the danger lies. Nature’s most destructive forces, as well as her strongest constructive ones, are silent in their operations; but when Science detects a silent, insidious enemy to human welfare, it is not only our duty to assume an attitude of self-defense and self-protection, but it should be regarded as folly not to do so.’ ❦ On high CO₂ levels connected to poor performance in schools: ‘The effects of breathing impure air thus far considered are pathological, but it has its pedagogical and economical aspects. Every observing teacher knows the immediate relation between the vitiated air in the school-room and the work he wishes the pupils to perform. Much of the disappointment of poor lessons and the tendency to disorder are due directly to this cause. The brain unsupplied with a proper amount of pure blood [oxygen] refuses to act, and the will is powerless to arouse the flagging energies; the general feeling of discomfort, dissatisfaction, and unrest which always accompanies a bad state of the blood. From an economical standpoint it would, of course, be impossible to estimate the financial waste of breathing impure air, but it can not but be enormous. In any discussion of the feasibility of incurring the additional expense of the most perfect ventilation, this loss occasioned by the want of such ventilation must not be ignored.’ ❂ Chapter III: The Air (pp.25-26) ❦ On ventilation, air filtration, and the super-spreading of diverse diseases in classrooms: ‘Wherever an unusual amount of unwholesome matter is being evolved, there especially should the purifying conditions be present; air in such places, to remain pure, must be changed in rapid succession, in order that dilution, diffusion, and oxidation may fulfill their legitimate functions. In a school-room the contaminating process can not but be rapid, and wherever ample provision is not made for rapidly changing the air of the room a dangerous condition of affairs is sure to exist. Bacteria of many forms, and spores of fungi, are also found in the air, and all these organisms are known to thrive in the organic impurities found in the air.’ ❂ Chapter IV: Examination Of The Air (p.33) ❦ On measuring CO₂ levels as a proxy to establishing content of (infectious) re-breathed air: ‘A complete analysis of impure air comprehends the quantitative and qualitative tests for carbonic [sic] dioxide, free ammonia, and other nitrogenous matter, oxidizable matters, nitrous and nitric acids, and hydrogen sulphide; but for ordinary practical purposes the determination of the CO₂ is by far the most important, and is ordinarily the only one which need be made. While the poisonous qualities of the air are not wholly due to the presence of the CO₂ per se, the amount of this gas found to be present is, in air made impure by respiration, generally a good measure for other impurities to which the poisonous quality is principally due. Owing to this fact, a careful test for the amount of CO₂ contained in a given atmosphere is generally the only one which need be made where air is tested merely to determine its respiratory purity.’ ❂ 📖 (Accessed 10 Apr 2024 ~ D. Appleton & Company / Google Books) The Ventilation and Warming of School Buildings ➤ ❂ My thanks to Maarten De Cock for alerting me to this gem of a book. ➲

❦ SARS-CoV-2 – the virus that causes Covid-19 – is airborne. In May 2021, the WHO officially recognised that SARS-CoV-2 is airborne via microscopic aerosols – meaning that the virus is transmissible through the air at both long and short range .

❦ ‘The occurrences of respiratory disorders among patients who survived for 30 days after the COVID-19 diagnosis continued to rise consistently, including asthma, bronchiectasis, COPD, ILD, PVD, and lung cancer. With the severity of the acute phase of COVID-19, the risk of all respiratory diseases increases progressively. Besides, during the 24-months follow-up, we observed an increasing trend in the risks of asthma and bronchiectasis over time, which indicates that long-term monitoring and meticulous follow-up of these patients is essential. These findings contribute to a more complete understanding of the impact of COVID-19 on the respiratory system and highlight the importance of prevention and early intervention of these respiratory sequelae of COVID-19. In this study, several key findings have been further identified. Firstly, our research demonstrates a significant association between COVID-19 and an increased long-term risk of developing various respiratory diseases. Secondly, we found that the risk of respiratory disease increases with severity in patients with COVID-19, indicating that it is necessary to pay attention to respiratory COVID-19 sequelae in patients, especially those hospitalized during the acute stage of infection. This is consistent with the findings of Lam et al., who found that the risk of some respiratory diseases (including chronic pulmonary disease, acute respiratory distress syndrome and ILD) increased with the severity of COVID-19. Notably, however, our study found that asthma and COPD remained evident even in the non-hospitalized population. This emphasizes that even in cases of mild COVID-19, the healthcare system should remain vigilant. Thirdly, we investigated differences in risk across time periods, as well as the long-term effects of COVID-19 on respiratory disease. During the 2-years follow-up period, the risks of COPD, ILD, PVD and lung cancer decreased, while risks of asthma and bronchiectasis increased. Fourthly, our study showed a significant increase of the long-term risk of developing asthma, COPD, ILD, and lung cancer diseases among individuals who suffered SARS-CoV-2 reinfection. This finding emphasizes the importance of preventing reinfection of COVID-19 in order to protect public health and reduce the potential burden of SARS-CoV-2 reinfection. Interestingly, vaccination appears to have a potentially worsening effect on asthma morbidity compared with other outcomes. This observation aligns with some previous studies that have suggested a possible induction of asthma onset or exacerbation by COVID-19 vaccination. It suggests that more care may be necessary for patients with asthma on taking the COVID vaccines. The underlying mechanisms associated with COVID and respiratory outcomes are not fully understood, but several hypotheses have been proposed. First, SARS-CoV-2 can persist in tissues (including the respiratory tract), as well as the circulating system for an extended period of time after the initial infection. This prolonged presence of the virus could directly contribute to long-term damage of the respiratory tissues, consequently leading to the development of various respiratory diseases. Second, it has been observed that SARS-CoV-2 infection can lead to prolonged immunological dysfunctions, including highly activated innate immune cells, a deficiency in naive T and B cells, and increased expression of interferons and other pro-inflammatory cytokines. These immune system abnormalities are closely associated with common chronic respiratory diseases – asthma, bronchiectasis, COPD, as well as the development of lung cancer. Next, SARS-CoV-2 itself has been shown to drive cross-reactive antibody responses, and a range of autoantibodies were found in patients with COVID-19. In conclusion, our research adds to the existing knowledge regarding the effects of COVID-19 on the respiratory system. Specifically, it shows that the risk of respiratory illness increases with the severity of infection and reinfection. Our findings emphasize the importance of providing extended care and attention to patients previously infected with SARS-CoV-2.’ ❂ 📖 (17 Feb 2024 ~ The Lancet: eClinical Medicine) Long-term risks of respiratory diseases in patients infected with SARS-CoV-2: a longitudinal, population-based cohort study ➤ © 2024 The Lancet: eClinical Medicine .

❦ Every single case in which a person with COVID-19 infects another person in a healthcare setting – patient, relative, or hospital staff member – is a significant failure of hospital procedures. Every single instance. ❂ © 2024 Professor Steve Robson MPH MD PhD ~ President, Australian Medical Association (AMA) . ➲

❦ ‘It is now well established that post-COVID syndrome ( PCS ) represents a serious complication in a substantial number of patients following SARS-CoV-2 infection. PCS is diagnosed when COVID-19-related symptoms persist for more than 3 months. It can occur even after an initially mild to moderate course of infection , and comprise a large variety of symptoms . Around 30% of PCS patients show neurological and neuropsychiatric sequelae , such as fatigue , depressive symptoms , and cognitive dysfunction . These are experienced as particularly debilitating, as they have detrimental effects on daily functioning in PCS patients and hamper a successful return to their jobs. Fatigue is a frequent and one of the most debilitating symptoms in post-COVID syndrome (PCS). Recently, we proposed that fatigue is caused by hypoactivity of the brain’s arousal network and reflected by a reduction of cognitive processing speed . Eighty-eight PCS patients with cognitive complaints and 50 matched healthy controls underwent neuropsychological assessment. Seventy-seven patients were subsequently assessed at 6-month follow-up. Patients showed cognitive slowing indicated by longer reaction times compared to control participants in a simple-response tonic alertness task and in all more complex tasks requiring speeded performance . Reduced alertness correlated with higher fatigue . Alertness dysfunction remained unchanged at 6-month follow-up and the same was true for most attention tasks and cognitive domains .’ ❂ 📖 (7 Nov 2023 ~ Journal of Neurology) Persistent cognitive slowing in post-COVID patients: longitudinal study over 6 months ➤ © 2023 Journal of Neurology .

❦ ‘The most common causes of acquired lymphocytopenia include: ➲ Protein-energy undernutrition. ➲ HIV infection. ➲ COVID-19 . ➲ Certain other viral infections. Patients with HIV infection routinely have lymphocytopenia, which arises from destruction of CD4+ T cells infected with the HIV virus. Patients with COVID-19 also frequently have lymphocytopenia ( 35% to 83% of patients ) . Lower lymphocyte counts portend a poor prognosis and an increased likelihood of requiring ICU admission and of dying from the disease. The cause of the lymphocytopenia is not completely understood, but COVID-19 can directly infect lymphocytes, and a cytokine-related apoptosis of the cells is likely. ➲ Lymphocytopenia is most often due to AIDS , and recently COVID-19 , or undernutrition, but it also may be inherited or caused by various infections, drugs, or autoimmune disorders. ➲ Patients have recurrent viral , bacterial , fungal , or parasitic infections .’ ❂ 📖 (Accessed 16 Sep 2023 ~ Merck & Co.) Entry for 'Lymphocytopenia' in Merck Manual ➤ © 2023 Merck & Co .

❦ I have seen a disproportionate number of young patients with advanced cancer over the last two years. They used to stand out: now it’s every week. The evidence points to direct Covid-driven mechanisms for rises in cancer risk. Will you hear about it in the news? Of course not. Covid’s over. It’s just anxiety now if you’re thinking about it. Except it’s not. It’ll take years for people to accept this. It’ll be too late. A number of my oncology colleagues have been commenting on how they’ve never seen such aggressively-progressive cancers in all their careers since Covid arrived. I’ve been seeing it as all these patients come to me. It isn’t normal. Alarm bells should be ringing loudly. The evidence: 📖 (22 Mar 2023 ~ Global Journal of Life Sciences and Biological Research) Cancer Related-Genes Enriched in Peripheral Blood Mononuclear Cells (PBMCs) of COVID-19 Patients: A Bioinformatics Study ➤ ‘SARS-CoV-2 can be considered a potential risk factor for increasing the probability of developing cancer.’ Study 1: 📖 (7 Jun 2022 ~ Frontiers in Oncology) SARS-CoV-2 M Protein Facilitates Malignant Transformation of Breast Cancer Cells ➤ ‘Coronavirus disease 2019 (COVID-19) has spread faster due to the emergence of SARS-CoV-2 variants, which carry an increased risk of infecting patients with comorbidities, such as breast cancer.’ Study 2: 📖 (9 Aug 2022 ~ Journal of Infection ) Is SARS-CoV-2 an oncogenic virus? ➤ ‘Gene expression of p53 [tumour suppressor] is downregulated in blood of COVID-19 patients. Downregulation persists at least 24 weeks after infection in long COVID-19 patients. Long-term reduction of p53 could have impact on carcinogenesis.’ 📖 (9 Aug 2022 ~ Journal of Infection) Letter to the editor: Is SARS-CoV-2 an oncogenic virus? ➤ Study 3: 📖 (22 Mar 2023 ~ Global Journal of Life Sciences and Biological Research) Cancer related-genes enriched in peripheral blood mononuclear cells (PBMCs) of COVID-19 patients. A bioinformatics study ➤ ‘Numerous cancer-related genes up-regulated in SARS-CoV-2-infected patients, particularly those genes participating in the cell-cycle regulation or engaged in cellular senescence processes.’ Study 4: 📖 (2 Jun 2023 ~ Biochimie) Possible cancer-causing capacity of COVID-19: Is SARS-CoV-2 an oncogenic agent? ➤ ‘One of the most worrying long-term effects of infection is the potential to induce malignant neoplasms, which will be a major health concern over the coming decades. SARS-CoV-2 infection affects many mechanisms that play a crucial role in cancer onset and progression including cell-cycle regulation, the RAAS system and inflammation / proliferation signaling pathways.’ ❂ Related reading : 📖 (9 Aug 2021 ~ Nature: Scientific Reports) More than 50 Long-term effects of COVID-19: a systematic review and meta-analysis ➤ 📖 (21 Jun 2021 ~ Nature: Scientific Reports) The risk of pancreatic adenocarcinoma following SARS-CoV family infection ➤ 📖 (4 Mar 2021 ~ Nature: Scientific Reports) COVID-19 engages clinical markers for the management of cancer and cancer-relevant regulators of cell proliferation, death, migration, and immune response ➤ 📖 (28 Jan 2021 ~ Nature: Scientific Reports) Meta-analysis of host transcriptional responses to SARS-CoV-2 infection reveals their manifestation in human tumors ➤ 📖 (25 Jan 2010 ~ Nature: Oncogene) Viral epigenome in human tumorigenesis ➤ 📖 (Dec 2006 ~ Yale Journal of Biology and Medicine) Viruses and human cancer ➤ ❂ © 2023 NHS Medical Consultant .

❦ The pandemic branding team deserves a gold star. Brain damage = ‘Brain fog’. Cardiac damage = ‘Fatigue’. Long Covid (Vascular disease affecting every organ system) = ‘Anxiety’. A leading cause of death worldwide = ‘Mild ™ ’. Hospital admissions = ‘Probably in with something else’. © 2023 Prognostic Chats . ➲

❦ Whenever I hear someone ask if we’re expected to continue masking in healthcare settings forever, I immediately think of Semmelweis – the man who discovered that healthcare workers’ dirty hands were causing fever and death in patients. The result of his discovery wasn’t the widespread implementation of hand hygiene though... Instead he was shunned, ostracized, lost his job and eventually institutionalized. It took around fifty years before the life-saving value of hand-washing was fully recognized in healthcare. Fifty years. It turns out that doctors didn’t take kindly to the idea that their own hands were unhygienic – and the source of disease and death for some of their patients. Despite the evidence, the denial was rampant and it was strong. The majority consensus was that Semmelweis was a crank... The resistance to the idea that the air we exhale while caring for patients can be unhygienic, and a source of illness and death for some, feels exactly the same to me. Despite the evidence, the denial is strong. Many prefer to cling to the status quo they knew before the pandemic. But that status quo was when we didn’t know better, and when we didn’t have such a virulent and dangerous new airborne pathogen in permanent circulation. Now that we do, and now that we know better, we should be willing to do better. So if the air we breathe can be unhygienic, and cause illness and death in our patients, and we know there’s a simple, effective solution – filtering it through a respirator – then it seems logical that this would become the new standard in our clinics, hospitals and long-term care facilities. Permanently. But as with Semmelweis’ experience, I expect that suggestion to get a lot of pushback, and for it to take a very long time for the medical field to accept that the old status quo is gone, and that masking in healthcare is the new normal. I just hope it won’t take another fifty years. © 2023 Dr. Lisa Iannattone . ➲

❦ It’s not so much that there isn’t validity to the desire to live as though Covid is behind us. It’s more that being an adult involves recognizing that choices have consequences. © 2023 Dr. Thomas Finch .

❦ ‘Some viruses are known to be associated with the onset of specific cancers. These micro-organisms – oncogenic viruses or oncoviruses – can convert normal cells into cancer cells. Seven oncogenic viruses are known to promote tumorigenesis [tumour creation] in humans: Human papillomavirus (HPV) Hepatitis B and C viruses (HBV, HCV) Epstein-Barr virus (EBV) Human T-cell leukemia virus 1 (HTLV-1) Kaposi sarcoma-associated herpesvirus (KSHV) Merkel cell polyomavirus (MCPyV) Recent research indicates that SARS-CoV-2 infection and COVID-19 progression may predispose recovered patients to cancer onset and accelerate cancer development . This hypothesis is based on the growing evidence regarding the ability of SARS-CoV-2 to modulate oncogenic pathways, promoting chronic low-grade inflammation and causing tissue damage.’ ❂ 📖 (25 Apr 2023 ~ International Journal of Molecular Sciences) Deciphering the Relationship between SARS-CoV-2 and Cancer ➤ © 2023 Costanzo et al / International Journal of Molecular Sciences.

❦ ‘ All subtypes of dementia , irrespective of patients’ previous dementia types, behaved like rapidly progressive dementia following COVID-19 [infection with SARS-CoV-2] , according to new research in the Journal of Alzheimer’s Disease Reports. In addition to this, the team of investigators found that the line of demarcation between different types of dementia became remarkably blurry post-COVID-19. Researchers found that the characteristics of a particular type of dementia changed following COVID-19, and both degenerative and vascular dementias started behaving like mixed dementia both clinically and radiologically . A rapidly and aggressively deteriorating course was observed in patients having insidious onset , slowly progressive dementia , and who were previously cognitively stable . Cortical atrophy was also evident in the study’s subsequent follow-ups. Coagulopathy involving small vessels and inflammation, which were further correlated with white matter intensity changes in the brain , was considered the most important pathogenetic indicator . The rapid progression of dementia, the addition of further impairments / deterioration of cognitive abilities, and the increase or new appearance of white matter lesions, suggest that previously compromised brains have little defense to withstand a new insult (i.e. a ‘second-hit’-like [SARS-CoV-2] infection).’ ‘Cognitive postscripts of COVID-19... characterized by multi-domain cognitive impairments, are now being reckoned as the most devastating sequelae of COVID-19.’ ❂ Source: 📖 (4 Apr 2023 ~ IOS Press / EurekAlert) New study shows SARS-CoV-2 infection accelerates the progression of dementia ➤ Source: 📖 (14 Feb 2023 ~ Dubey et al / Journal of Alzheimer’s Disease) The Effects of SARS-CoV-2 Infection on the Cognitive Functioning of Patients with Pre-Existing Dementia ➤ © 2023 IOS Press / Journal of Alzheimer’s Disease .

‘We are entering a phase of long COVID and chronic disability.’ ❂ ❦ ‘As the numbers of hospitalizations and deaths are dropping, many individuals declare the pandemic all but over, comforted by the belief that infections are mild and less dangerous than the seasonal flu. However, the scientific literature these last few weeks has been filled with deeply concerning reports. We are entering a phase of long COVID and chronic disability. The number of COVID-19 cases in the United States is unknown since our case reporting system has become unreliable and substantially undercounts cases. In England, as of the week ending March 7, 2023, 1 in 40 people is positive for COVID-19 , and reinfections are frequently occurring. It is estimated that as of November 9, 2022, 94% of the U.S. population has been infected by SARS-CoV-2 , and 65% of the United States population has been infected multiple times . The odds of self-reported long COVID were 28% less after the second infection. Unfortunately, the damage of long COVID from a second infection adds to the first . One of the most concerning long-term effects of COVID-19 is immune dysfunction or hypofunction . Confirmatory research was reported this week, and summarized in a National Institute of Health news release which stated: ‘… findings suggest that SARS-CoV-2 infection damages the CD8⁺ T cell response , an effect akin to that observed in earlier studies showing long-term damage to the immune system after infection with viruses such as hepatitis C or HIV .’ The authors conclude that this dysfunction causes lasting damage and may ‘contribute to long COVID, perhaps rendering patients unable to respond robustly to subsequent infections by SARS-CoV-2 variants or other pathogens .’ * * 📖 (20 Mar 2023 ~ National Institutes for Health) SARS-CoV-2 infection weakens immune-cell response to vaccination ➤ These findings mirror those reported by Files et al who state: ‘Overall, expression of these activation and exhaustion markers indicated more severe immune dysregulation of CD8 ⁺ T cells in the hospitalized group.’ And they found that ‘ CD8⁺ T cell expression of exhaustion markers increased in non-hospitalized individuals over time ’. * * 📖 (4 Jan 2021 ~ Journal of Clinical Investigation) Sustained cellular immune dysregulation in individuals recovering from SARS-CoV-2 infection ➤ The authors’ finding of damage to the immune system “akin” to HIV is very concerning, as is the amplification of this result in the NIH news release. Infection Control Today previously reported that the probable cause of the surges in infections we are seeing is an immune dysfunction caused by COVID-19 . With minimal public health interventions, Sweden also experienced surges in respiratory syncytial virus (RSV) cases. Most recently, Sweden has undergone a significant surge in seasonal flu, with reports from the Public Health Agency of Sweden of unusually severe cases. These [Swedish influenza] cases have occurred in ‘... people under the age of 18 without underlying disease or condition, and have been very seriously ill with complications such as myocarditis or encephalitis.’ Other diseases are also rising , exemplified by reports of record-high severe Streptococcal infections and Candida auris . These spikes in infections caused by multiple pathogens are associated with the SARS-CoV-2 pandemic and the mounting evidence of post-COVID-19 immune dysfunction. Vaccinations can not only reduce the incidence of severe disease, but can also help to prevent long COVID, reducing the incidence by 30% to 40%. However, we have expressed concern regarding the bivalent booster’s effectiveness, and reported a rapid waning of booster-induced immunity in the elderly. [See Footnote.] Recently, researchers from the United States found that the relative bivalent booster effectiveness at 5 to 7 months in preventing hospitalizations relative to monovalent vaccine dosages (2, 3, or 4) was 42% and 59% compared to no vaccination. Using the third vaccine dose as a baseline, the UK Health Security Agency found that an additional (fourth) vaccine dosage had effectiveness against hospitalizations at 10 weeks of only 50% .’ Source: 📖 (21 Mar 2023 ~ Infection Control Today) COVID-19: Study Suggests Long-term Damage to Immune System ➤ ❂ Footnote: On waning vaccine effectiveness * ‘Vaccine effectiveness is an important point. Although much of the younger population received a get-out-of-hospital free card for the latest variant, senior citizens were in its crosshairs. During the last 6 months (since May of 2022), those over the age of 75 had a higher rate of hospitalizations than in the Delta surge; those between the ages of 65 and 75 had approximately the same. Both age groups continue to be at high risk for death and disability. However, data showed that for those 65 years of age and older, the monovalent vaccine’s (2 or more doses) effectiveness for preventing hospitalizations fell to 28% in less than a year. Results were worse for those individuals under 65 years – only 19%.’ * 📖 (24 Feb 2023 ~ Infection Control Today) How Soon Is Another Booster Needed? Durability of Vaccine-Induced Immunity ➤ ❂ © 2023 Infection Control Today . ➲

❦ ‘Long COVID impacts children of all ages . Children with Long COVID experience fatigue, post-exertional malaise (PEM), cognitive dysfunction, memory loss, headaches, orthostatic intolerance, sleep difficulty and shortness of breath. ❦ Post-exertional malaise (PEM) = The worsening of symptoms following even minor physical or mental exertion, with symptoms typically worsening 12 to 48 hours after activity and lasting for days or even weeks. ❦ Cognitive dysfunction = deficits in attention, verbal and non-verbal learning, short-term and working memory, visual and auditory processing, problem solving, processing speed, and motor functioning. ❦ Orthostatic intolerance = The inability to remain upright without symptoms. Liver injury has been recorded in children who were not hospitalized during acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections, and although rare, children who had COVID-19 have increased risks of acute pulmonary embolism, myocarditis and cardiomyopathy, venous thromboembolic events, acute and unspecified renal failure, and type 1 diabetes. Infants born to women who had COVID-19 during pregnancy were more likely to receive a neurodevelopmental diagnosis in the first year after delivery. A paediatric Long COVID centre’s experience treating patients suggests that adolescents with a moderate to severe form of Long COVID have features consistent with myalgic encephalomyelitis (ME) / chronic fatigue syndrome (CFS) . ❦ Myalgic encephalomyelitis / Chronic fatigue syndrome = (ME/CFS) is a condition that causes extreme tiredness and a range of other symptoms. Other symptoms of ME/CFS may include: ⊙ Tender lymph nodes in the neck or armpits. ⊙ A sore throat that happens often. ⊙ Digestive issues, like irritable bowel syndrome. ⊙ Chills and night sweats. ⊙ Allergies and sensitivities to foods, odors, chemicals, light, or noise. ⊙ Muscle weakness. ⊙ Shortness of breath. ⊙ Irregular heartbeat. Children experiencing Long COVID have hypometabolism in the brain similar to the patterns found in adults with Long COVID. ❦ Hypometabolism in the brain = Characterized by decreased brain glucose consumption, is a common feature of many neurodegenerative diseases . The initial hypometabolic brain state created by characteristic risk factors may predispose the brain to acquired epilepsy and sporadic Alzheimer's and Parkinson's diseases . Long-term pulmonary [lung] dysfunction is found in children with Long COVID, and in those who have recovered from COVID-19. Children with Long COVID were more likely to have had attention deficit hyperactivity disorder, chronic urticaria and allergic rhinitis before being infected. Fatigue, headache, dizziness, dyspnoea, chest pain, dysosmia, dysgeusia, reduced appetite, concentration difficulties, memory issues, mental exhaustion, physical exhaustion and sleep issues were between 2 and 36 times more likely in individuals with Long COVID aged 15-19 .’ ❦ Dyspnoea = shortness of breath, or breathlessness. ❦ Dysosmia = a change in the ability to smell. ❦ Dysgeusia = a change in perception of taste. ❂ 📖 (13 Jan 2023 ~ Nature Reviews: Microbiology) Long COVID in children ➤ 📖 (13 Jan 2023 ~ Nature Reviews: Microbiology) Long COVID: major findings, mechanisms and recommendations ➤ © 2023 Nature.

❦ COVID-19 is fighting back by generally depressing the whole adaptive immune system. We are showing narrow resilience to COVID reinfections due to adapting – but we are becoming more vulnerable in general to infections of all kinds. ❦ Worst case scenario: a single infection causes on-going and progressive immunodeficiency . ❦ Best case scenario: a single infection causes temporary immunosuppression , and we suppress COVID transmission enough to allow recovery. ❦ Most likely scenario, medium-term: immunosuppression that becomes continuous and possibly progressive due to reinfections. Reduced immune function after a viral infection is not unusual. Many viruses do this. The concerning issue is the length and breadth of the immune system dysfunction, coupled with emerging evidence of other pathogens taking advantage. ❂ ❦ Immunosuppression ~ Suppression of the immune system and its ability to fight infection. ❦ Immunodeficiency ~ A state in which the immune system's ability to fight infectious diseases and cancer is compromised, or entirely absent. ❂ 📖 (13 Jan 2022 ~ Nature: Immunology) Immunological dysfunction persists for 8 months following initial mild-to-moderate SARS-CoV-2 infection ➤ © 2022 Dr. Noor Bari, Emergency Medicine ➲

❦ ‘SARS-CoV-2 enters the human body through the ACE2 receptor and exerts different effects on various systems of the human body. Regarding the impact of COVID-19 on the reproductive system, ACE2 is highly expressed in the testis of the male reproductive system. A study of scRNA-seq data in adult human testes showed that male gonads may be infected with SARS-CoV-2, which may cause male reproductive dysfunction. The increase in pro-inflammatory cells and decrease in androgens in men infected with SARS-CoV-2 may lead to a decreased gonadal function. SARS-CoV-2 may also infect the ovaries, uterus, vagina, and placenta in the female reproductive system through the expression of ACE2 receptors, leading to infertility, menstrual disorders, and fetal distress. Pregnant women infected with SARS-CoV-2 have a lower incidence of vertical transmission of the virus to newborns, which may be related to the lower expression of ACE2 and TMPRSS2 in the placenta and an increase in SARS-CoV-2-specific antibodies and IgG during pregnancy; however, it may cause inflammation of the placenta, which increases the risk of pre-eclampsia and placental abruption during pregnancy. ACE2 is expressed at a high level in testicular tissues compared to that in the ovaries and uterus. Therefore, male patients may be slightly more affected by SARS-CoV-2 infection than females.’ ❂ 📖 (20 Sep 2022 ~ Frontiers in Cellular and Infection Microbiology) Therapeutic prospects of ceRNAs in COVID-19 ➤ © 2022 Lin Liu et al / Frontiers in Cellular and Infection Microbiology.

‘Older people who were infected with COVID-19 show a substantially higher risk – as much as 50% to 80% higher – of developing Alzheimer’s disease within a year. And the highest risk was observed in women at least 85 years old.’ ⊙ ❦ ‘ Older people who were infected with COVID-19 show a substantially higher risk – as much as 50% to 80% higher than a control group – of developing Alzheimer’s disease within a year , according to a study of more than 6 million patients 65 and older . And the highest risk was observed in women at least 85 years old . The findings showed that the risk for developing Alzheimer’s disease in older people nearly doubled (0.35% to 0.68%) over a one-year period following infection with COVID. The researchers say it is unclear whether COVID-19 triggers new development of Alzheimer’s disease or accelerates its emergence . “The factors that play into the development of Alzheimer’s disease have been poorly understood, but two pieces considered important are prior infections, especially viral infections, and inflammation,” said Pamela Davis, Distinguished University Professor and Professor at the Case Western Reserve School of Medicine, the study’s co-author. Previous COVID-related studies led by CWRU have found that people with dementia are twice as likely to contract COVID.’ ❂ Source: 📖 ( 13 Sep 2022 ~ Science Daily / Case Western Reserve University) Risk factor for developing Alzheimer's disease increases by 50-80% in older adults who caught COVID-19 ➤ Source: 📖 (13 Sep 2022 ~ Journal of Alzheimer’s Disease) Association of COVID-19 with New-Onset Alzheimer’s Disease ➤ © 2022 Journal of Alzheimer’s Disease / Science Daily .

❦ What should be a higher priority for society: preventing pigs from becoming sick, or preventing human illness? Personally, I place a higher value on preventing human illness. I think most would agree. Why, then, are pig barns far better ventilated than schools? An airborne virus has killed 900,000 Americans, and has left countless others suffering from Long Covid along with its chronic, and perhaps permanent, mental and physical afflictions. We know that ventilation and the filtration of indoor air prevents illness. The manifold benefits of improved ventilation are well-documented and uncontroversial. Professor Don Milton has been publishing studies for over twenty years showing that improved ventilation reduces respiratory illnesses and absences, though his findings were largely ignored. Yet we’ve done almost nothing to improve air filtration and ventilation in schools, workplaces, restaurants, and other buildings. The USA’s CDC (Centers for Disease Control and Prevention) gives lip service to ventilation – but has issued no minimum ventilation requirements, and offers no specific guidance. 📖 (26 Feb 2021 ~ CNN Health) CDC must encourage better ventilation to stop coronavirus spread in schools, experts say ➤ On the other hand, great cost and effort is put into ventilating and filtering the air in pig barns in order to prevent disease outbreaks. Let’s compare the ventilation and air-filtration of pig barns with buildings inhabited by human beings. First, note that airborne spread of Porcine Reproductive and Respiratory Syndrome (PRRS) was readily accepted based on circumstantial evidence and lab studies. French farms even installed HEPA filtration systems in pig barns, despite “no hard data to support” their use. Contrast this with the stubborn, year-long denial of airborne Covid spread by the WHO and CDC, despite abundant evidence. The precautionary principle is obeyed when pigs’ health is at stake, but not when human health is at risk. Incredibly, droplet dogma still reigns supreme in some places. Many are still fighting against appallingly ignorant public officials and nonsensical guidelines in Australia. [Insert ubiquitous poster from your hospital, doctor’s surgery, pharmacy, bowling alley or supermarket extolling the virtues of hand-washing and hand-sanitiser in a pandemic essentially driven by aerosol transmission .] Some officials haven’t gotten the memo yet: Covid is airborne . Many careful, controlled studies of ventilation and air-filtration in livestock facilities have been carried out, and the cumulative evidence compiled leaves little doubt of their effectiveness at preventing disease in farm animals. One of many examples: 📖 (July 2006 ~ Canadian Journal of Veterinary Research) Further evaluation of alternative air-filtration systems for reducing the transmission of Porcine reproductive and respiratory syndrome virus by aerosol ➤ In contrast, before Covid, research on ventilation, air-filtration and disease in human dwellings was pretty sparse. Linsey Marr, Don Milton, Julian Tang, Yuguo Li and others were lone voices in the wilderness, shouting into a void, and ignored by the CDC and the WHO. For buildings that humans inhabit, enforced minimum ventilation requirements are almost non-existent. The HVAC* in a school or nursing home can be completely non-functional, creating a superspreader environment, and with no legal consequences. * HVAC = Heating, Ventilation, and Air Conditioning. This is not hypothetical. Here is one documented instance in which all 226 residents in a Canadian nursing home contracted Covid, resulting in over 70 deaths. 📖 (14 May 2020 ~ CBC News) Investigators look into catastrophic outbreak that infected all residents of TMR seniors' home, killing 70 ➤ The cause? A non-functioning ventilation system. And this was a less transmissible, pre-Alpha SARS-CoV-2 variant. 📖 (15 May 2020 ~ Radio Canada) Un CHSLD infecté à 100%, avec un système de ventilation en panne, préoccupe Québec ➤ The same private company owned another nursing home in which 96% of residents and 116 employees caught Covid, leading to the death of 66 residents. I think we can surmise that the ventilation in this facility was also very poor. Why were the ventilation systems in these nursing homes not audited? Because such auditing is simply not done – not in nursing homes, schools, workplaces or restaurants. Ventilation and air-filtration recommendations exist, but not enforced standards. They’re essentially voluntary. What about pig barns? While there are no legal requirements, the ventilation and air-filtration systems at these facilities are assiduously checked every day by a worker whose sole duty is to inspect and maintain the ventilation equipment. 📖 (12 Nov 2016 ~ National Hog Farmer) Hog barn filtration system audits imperative to disease control ➤ No aspect of the system is left unchecked. “Look for any gaps or openings that would allow dirty air in... Make sure chutes collapse properly, creating a good seal.” “Cracked fan housings or a broken shroud” are checked for, and “weep holes plugged with a rubber stopper...” But daily inspection is only the start. In addition, at least once a month, a system filtration technician (SFT) audits the ventilation system, coaching the on-site manager. Another monthly audit is performed by the herd veterinarian, who guides the SFT. In contrast, human dwellings (such as nursing homes) are virtually never audited, even during a pandemic. It apparently requires a court order for such an audit to occur. Are HVAC systems in human-occupied buildings well maintained? HVAC expert Jeffrey Siegel: “The best HVAC in the world performs poorly when it’s not well maintained, and the usual standard is ‘not well maintained’.” The same article* describes an HVAC unit installed upside-down in a large store, making it impossible to change the filter, meaning that “... the air inside the store would be that much crummier”. It was like “a thousand other HVAC mistakes” Siegel has seen: “... dampers supposed to admit outside air into a building rusted open or shut, badly-installed filters letting air pass around their edges, forced-air fans running 18% of the time. In theory, HVAC heats and air-conditions. In practice, it doesn’t always ventilate... or filter.” * 📖 (9 Nov 2020 ~ Wired) The Next Covid Dilemma: How to Make Buildings Breathe Better ➤ What sort of air filters are used for pig barns? First, a mesh net catches larger objects in the air, such as feathers. Then the air goes through a MERV 8 ‘pre-filter’. This pre-filter is of a higher grade than the filters used in many schools, which are MERV 7. After passing through the MERV 8 pre-filter, air entering pig barns is filtered by MERV 15 air filters – similar to the filters used in hospitals. Very few schools, workplaces, nursing homes or restaurants use anything above MERV 11. MERV 15 is unheard of. Does such high-quality ventilation and filtration of pig barns reduce disease outbreaks? Of course it does, as the extensive literature on livestock-facility ventilation and air-filtration attests. 📖 (May 2012 ~ Viruses) Evaluation of the long-term effect of air filtration on the occurrence of new PRRSV infections in large breeding herds in swine-dense regions ➤ However, there is a potential problem: what if some of the dirty air from the human-occupied office building on a farm were to leak into the pig barn? Perish the thought! To allow pigs to breathe the same filthy air breathed by humans would be unthinkable. Therefore, pig farms are designed so that none of the filthy air from the farm’s human office is allowed to contaminate the pristine, highly-filtered air of the pig barn. (“If there is dirty air in the office, it will stay in the office.”) The notion of providing pig-quality air to the office is considered so absurd that it doesn’t merit consideration. After all, if the health of the workers on a farm is improved, this doesn’t affect profits. A sick pig, on the other hand, hurts the bottom line. Priorities... One article on the ventilation and air-filtration of pig barns notes a peculiar “side benefit” of improving the pigs’ air: human workers notice the better air, and seem healthier for it. How much healthier? No-one knows, as such trivial topics as worker health are not researched. So why is the air quality in human buildings so poor? Why haven’t greater efforts been made to improve indoor air quality (IAQ), the enormous benefits of which are well-known and uncontroversial? After all, we regulate water and food safety. Why not indoor air? The WHO recommends schools and other buildings have at least 6 air changes per hour (ACH). A typical school HVAC provides less than 1 ACH. IAQ experts recommend CO2 levels be less than 800 ppm (or less than 700 ppm in a pandemic), but CO2 levels regularly reach much higher levels in schools. I’ve occasionally registered levels near 3000 ppm; others report readings higher than 4000 ppm. What about hotels? I stayed in a room at the Disney Caribbean Resort Hotel with my brother. CO2 reached well over 3000 ppm each night. I did a CO2 decay study, and found that the room got 0.11 air changes per hour. Not good. It’s long past time to greatly improve ventilation and air filtration by imposing serious, enforced IAQ standards in nursing homes, schools, workplaces and other public spaces. Many aerosol and IAQ experts have been calling for this for a long time. 📖 (14 May 2021 ~ Science) A paradigm shift to combat indoor respiratory infection ➤ Only recently have their calls gained traction. The vast majority of people would be much better off if IAQ were improved through better ventilation and filtration. We spend the majority of our lives indoors. Proper air filtration and ventilation would enormously improve the air we breathe. When we think of air pollution, we usually think of lung damage. But polluted air damages all organs of the body. With cleaner air, brain function would improve; heart attacks and strokes would fall; illness would be reduced. It works for pigs. It can work for humans, too. Air pollution is possibly the single largest health problem in the world. It causes the loss of more years of life than alcohol and narcotics, unsafe water, HIV, malaria, and war combined. Cleaning the air we breathe is essential. However, the pecuniary interests of the 1% of landlords, real-estate magnates, business owners, and capitalists in general might not be so well-served. Installing better ventilation systems and air filters in human dwellings might put a dent in their investment returns – an unthinkable notion. To sum up. Improving indoor air quality in human dwellings merely improves the health and well-being of humans – a minor consideration – while improving air quality in pig barns improves profits: a sacred objective, and the chief aim of life under capitalism. ❂ Related : 📖 (10 Aug 2020 ~ The Conversation) How to use ventilation and air filtration to prevent the spread of coronavirus indoors ➤ Related : 📖 (28 Sep 2020 ~ Quartz) What everyone should know about ventilation and preventing Covid-19 ➤ ❂ © 2022 Ryan Hisner . ➲

❦ ‘ Infection with SARS-CoV-2 can cause cardiovascular problems for up to a year , not just during the acute phase, a large study has found. One year after covid-19 infection people were at higher risk of cardiovascular disease , including cerebrovascular disorders , dysrhythmias , ischaemic and non-ischaemic heart disease , pericarditis , myocarditis , heart failure , and thromboembolic disease . Even those who had not been admitted to hospital with covid-19 were at risk of these problems , but the risk increased with the severity of the infection, from people not admitted to hospital to those admitted to intensive care. Those who had had covid-19 had a 72% increased risk of heart failure , 63% increased risk of heart attack , and 52% increased risk of stroke compared with controls. The researchers wrote that the increased risks “were evident regardless of age , race , sex , and other cardiovascular risk factors , including obesity, hypertension, diabetes, chronic kidney disease, and hyperlipidemia; they were also evident in people without any cardiovascular disease before exposure to covid-19 , providing evidence that these risks might manifest even in people at low risk of cardiovascular disease.” The researchers said that the risk of cardiovascular disease in people who have had covid-19 is substantial . While the best way to prevent cardiovascular problems is to prevent infection in the first place , governments and health systems must prepare to deal with possible big problems in future. The cardiovascular problems seen in some people who have had covid-19 are chronic and may have long-lasting consequences for the individual and for health systems , economic productivity , and life expectancy , the researchers say.’ ❂ 📖 (7 Feb 2022 ~ Nature: Medicine) Long-term cardiovascular outcomes of COVID-19 ➤ 📖 (14 Feb 2022 ~ The BMJ) Covid-19: Even mild infections can cause long term heart problems, large study finds ➤ Related: 📖 (10 Feb 2022 ~ Nature: News) Heart-disease risk soars - even with a mild case ➤ © 2022 The British Medical Journal .

❦ SARS-CoV-2 infection in pregnancy is known to confer a risk of increased morbidity and mortality for the mother. Placental and fetal infection with SARS-CoV-2 have been rare to date; SARS-CoV-2 infection in pregnancy appears most likely to impact fetal brain development via maternal and placental immune activation. Maternal and placental immune activation may impact the placenta and developing fetal brain via induction of immune activation and proinflammatory cytokine production, dysregulation of serotonin/other neurotransmitter signaling, and increased oxidative stress. ❂ 📖 (13 Feb 2022 ~ Trends in Molecular Medicine) COVID-19 in pregnancy: implications for fetal brain development ➤ © 2022 Shook et al / Trends in Molecular Medicine.