I’m still scared of catching COVID. As a young, healthy, bivalent-enhanced physician, I no longer worry about ending up on a ventilator, but it seems plausible that even a mild case of the disease could shorten my life or leave me with chronic fatigue, breathing problems, and brain damage. fog. About one in 10 Americans seem to share my concern, including many doctors. “We know that many devastating symptoms can persist for months,” wrote physician Ezekiel Emanuel last May in The Washington Post. “Like everyone, I want this pandemic nightmare to end. But I’m also desperately afraid of living an exhausted life of mental confusion or numbness.’
Lately, I’ve come to think that our concerns might be better placed. As the pandemic continued, data emerged to clarify the dangers posed by COVID in the weeks, months, and years following infection. Taken together, their implications are surprising. Some people’s lives have been devastated by the long COVID; they are trapped in confusing symptoms that seem to persist indefinitely. For most vaccinated people, however, the worst complications won’t occur in the early phase of illness when you first feel feverish and stuffy, nor can the most serious risks be said to be “long-term.” Rather, they appear during the environment post-infection phase, a period that lasts about 12 weeks after you become ill. This time period is so threatening, in fact, that it really should have its own, familiar name: average COVID.
How much of a threat is the average COVID? The answer is obscured to some extent by sloppy definitions. Many studies lump different, dire results into one giant bucket called “long COVID.” Diseases that occur after only four weeks, along with those that appear many months later, are considered the same. The CDC, for example, suggested in a study conducted last spring that one in five adults who contract the virus will suffer one of 26 medical complications starting at least one month after infection and lasting up to a year. All of these are called “post-COVID or long-COVID conditions”. A series of influential analyzes looking at US veterans described an incidence of new heart, kidney and brain disease (even among the vaccinated) over a similarly broad time period. The study authors refer to them, grouped together, as “a long COVID and its myriad complications.”
But the risks described above may only be most significant in the first few weeks after infection and disappear over time. When scientists analyzed Sweden’s national health registry, for example, they found that the chance of developing a pulmonary embolism — an often deadly clot in the lungs — was a startling 32 times higher in the first month after testing positive for the virus; then rapidly declined. Clots were only twice as common 60 days after infection, and the effect was indistinguishable from baseline after three to four months. The risk of heart attack and stroke after infection is also obvious and decreases just as quickly. In July, UK epidemiologists confirmed the Swedish findings, showing that increased rates of cardiovascular disease among COVID patients can be detected up to 12 weeks after they become ill. Then the danger was gone.
All of this is to be expected, given that other respiratory infections are known to cause a temporary spike in patients’ risk of cardiovascular events. Post-viral blood clots, heart attacks and strokes tend to rage like a summer storm. A very recent journal article Circulation, also based on data from the United Kingdom, found that the effects of COVID were more long-lasting, with an increased chance of such events lasting almost a full year. But even in this study, the authors saw the risk drop most dramatically in the first two weeks. I’ve already read dozens of similar analyses, using data from many countries, that agree with this basic thesis: the greatest dangers lie in the weeks, not months, after contracting COVID.
Yet many have concluded that the dangers of COVID are endless. “What’s particularly worrisome is that these are really lifelong conditions,” Ziyad Al-Ali, lead researcher on the Veterans Affairs study, told Financial Times in August. A Cleveland Clinic cardiologist suggested that being infected with SARS-CoV-2 may contribute even more to cardiovascular disease than being a chronic smoker or being obese. But if the experts who support this assumption are right—and the lethal dangers of COVID really do last a lifetime (or even many months)—then it’s not yet visible at the health system level. By the end of Omicron’s surge last winter, one in four Americans — about 84 million people — had been newly infected with the coronavirus. This was in addition to 103 million infections before Omicron. Still, six months after the surge ended, the number of emergency room visits, outpatient visits and hospital admissions for adults nationwide were slightly lower than they were at the same time in 2021, according to an industry report released last month. In fact, emergency room visits and hospitalizations in 2021 and 2022 were lower than previously before the pandemic. In other words, a rising tide of long-standing COVID-related medical conditions affecting nearly every organ system is nowhere to be found.
If mild infections routinely lead to fatal outcomes with a delay of months or years, then we should see it in death rates as well. The number of excess deaths in the U.S. — meaning those that occurred outside of historical norms — should still rise, long after cases have fallen. Still, the U.S. excess death rate fell to zero last April, about two months after the winter spike ended, and has remained relatively low ever since. Here, as around the world, overall death rates follow acute infection rates, but only briefly. The second wave of deaths — a long wave of COVID — never seems to stop.
Even the most familiar ailments of “long COVID”—severe fatigue, cognitive impairment, and breathing problems—are usually at their worst during the middle phase after infection. An early analysis of symptom-tracking data from the UK, US and Sweden found that the proportion of those who survived the effects of COVID fell by 83 per cent four to 12 weeks after the onset of illness. The UK government also reported much higher rates of moderate COVID compared to long-term COVID: In its study, 11 percent of people who caught the virus had long-term problems such as weakness, muscle aches and loss of smell, but this percentage dropped to 3 percent by 12 weeks after infection. The UK saw a slight drop in the number of people reporting such problems over the spring and summer; and a recent US government survey found that about half of Americans who have had any symptoms of COVID for three months or more have now recovered.
This slow, steady resolution of symptoms is consistent with what we know about other postinfectious syndromes. A study of adolescents recovering from mononucleosis caused by the Epstein-Barr virus found that 13 percent of subjects met criteria for chronic fatigue syndrome at six months, but that percentage was nearly half at one year and nearly half again at two. A study of chronic fatigue after three different infections—EBV, whooping cough, and Ross River virus—identified a similar pattern: frequent symptoms after infection that gradually subsided over months.
The prevalence of the average COVID does nothing to negate the reality of the long COVID, a catastrophic condition that can shatter people’s lives. Many long-haul carriers experience continuous symptoms and their cases can develop into complex chronic syndromes such as ME/CFS or dysautonomia. As a result, they may need specialist medical care, permanent job placement and ongoing financial support. Recognizing the small chance of such tragic outcomes may be enough to drive some people to try to avoid infection or re-infection with SARS-CoV-2 at all costs.
But if you’re like me and trying to calibrate your behavior to match some personally acceptable level of risk from COVID, then it’s helpful to keep in mind the difference between the medium-term and long-term complications of the virus. The average COVID may be limited in time, but it is far from rare – and not always mild. This can mean a month or two of extreme fatigue, crushing headaches and nasty chest pain. It can lead to life-threatening medical complications. It needs recognition, research and new treatments. For millions of people, the average COVID is as bad as it gets.