Worms in Your Spaghetti

#2 Worms in your spaghetti

INCREASES IN DISEASE PREVALENCE AND SEVERITY A LIKELY RESULT OF COVID-19 AND LONG COVID. THE “IMMUNITY DEBT” HYPOTHESIS IS UNFOUNDED. 

Written 2.17.2023

Updated 11-28-23

by Shea O’Neil

Come for the Spaghetti, Stay for the Cannoli

Misinformation is often intertwined with facts that are either intentionally or unintentionally placed as a way to propagate a narrative at the expense of responsible, scientific messaging. 

We have dubbed this column, “Worms in your Spaghetti'' with the purpose of pulling out “worms” of misinformation, separating out the “spaghetti” of data, and focusing in on the “meatballs” (or chunks of hearty vegetables, depending on your preference) of good information. 

Finally, in our wrap-up section, “the Cannoli”, we summarize and learn what we can do to fight back against misinformation, and send any leftovers in a "doggy bag" appendix at the end of each article. 

Today’s Dish: COVID-19 and Long COVID Effects vs “Immunity Debt”

 
“A hypothesis is an assumption made before any research has been done. It is formed so that it can be tested to see if it might be true. A theory is a principle formed to explain the things already shown in data. Because of the rigors of experiment and control, it is much more likely that a theory will be true than a hypothesis” [Merriam Webster]. 

Today we will be examining whether the huge increases in viral prevalence and severity that we are seeing with the flu, RSV, and COVID-19 are due to the hypothesis of "immunity debt" or the theory that these increases are a result of COVID-19 infection and long COVID in the population. Let’s start by weighing the evidence.  

Weighing the Evidence: 

COVID-caused Immune Damage

1. COVID-19 infections cause damage to the immune system. Studies show that when you damage the cells of the immune system, you become more vulnerable to future infections and worsened health outcomes. 

2. Infections and reinfections from SARS-CoV-2, the virus that causes COVID-19 infection, deplete key cells of the immune system and this damage is long-term [1] [2] [3] [4] [72][74].

3. The depletion of these cells undermines the ability of the immune system to fight other infections [5][6][7][8][9][10][68][69] [71], and worsens long-term health outcomes across a wide variety of bodily systems [11][12][13].

4. A 2020 article in the New York Times headlined that the coronavirus short-circuits the immune system in a manner similar to how HIV causes AIDS [14]. Both diseases cause immune dysregulation involving decreased T-cells, natural killer cells, and B-cells, as well as increased cytokines that create serious immunological dysfunction.  

5. A March 2023 Nature study showed that COVID-19 causes damage to the immune system for at least 6 months after even mild cases, and that this immune damage affects t cells, and has cascading effects on the immune system's ability to clear the virus fully, leading to further bodily damage [67]. 

6. A 2023 study, the first-in-human T cell activation PET imaging study of individuals in the post-acute phase of SARS-CoV-2 infection, researchers found COVID-19 may result in persistent T cell activation in a variety of body tissues, that this activity may persist for years following initial symptom onset and associate with systemic changes in immune activation as well as the presence of Long COVID symptoms, and that SARS-CoV-2 persistence in gut tissue may contribute to these processes [72]. 

7. A study (November 29th 2022) has shown that among RSV-infected children in 2022, approximately 19% had prior documented COVID-19 infection, significantly higher than the 10% among uninfected children. These results suggest that prior COVID-19 infection is a risk factor for RSV infection.  The study notes: “In 2022, the incidence rate was higher than in any other previous years including for peak months in 2021 in children 5 and under” [16], showing this trend is increasing.

8. And finally, a study published October 13th, 2023 concluded that COVID-19 contributed to the RSV surge in 2022, likely due to its long-term adverse effects on both the immune system and respiratory system [71]. The authors state: "Individuals infected with COVID-19 can have long-lasting changes in both innate and lymphocyte-based immune functions, precisely the systems most engaged in defense against respiratory viruses. If the immune debt… was the main contributor, we would expect that the level of RSV infection in 2022 to be similar to that in 2021. In 2022, significantly more children contracted COVID-19 due to the relaxation of preventive measures and the dominance of the highly transmissible Omicron variant. Studies show that SARS-CoV-2 virus fragments can persist in the body and have the ability to stimulate tissue-specific immunity in children and children affected by long COVID may have a compromised cellular immune response."

9. A 2022 Study in the Journal of Clinical Medicine suggested that: “children affected by Long COVID may have a compromised ability to switch from the innate to the adaptive immune response, as supported by our data showing a contraction of naïve and switched B cell compartment and an unstable balance of regulatory T lymphocytes occurring in these children” [73].

Historical data also shows COVID-19 infection and reinfection can cause damage to the immune system that makes one more susceptible to getting other infections, and makes it harder to fight off those infections resulting in more severe cases. 

1. We can see this in the unique case of New Zealand, which had low COVID-19 in its population in 2021: When they suddenly removed pandemic protections and increased travel, they saw an increase in RSV cases (as would be expected when protective measures are taken away). What was notable, however, was that the severity of RSV cases did not increase at this point [e]. In other countries, however, such as the US, which–unlike New Zealand at that time–had high transmission of COVID-19 in the population and were in the second year without mask mandates or other protections, there were notable increases in both cases and severity (see cases and hospitalizations graphs in Spaghetti section). In other words, those places with higher prior COVID-19 infections in the population had not just more RSV cases but worsened severity of cases of RSV, reinforcing the studies on COVID-caused immune damage that negatively impacts one's ability to fight other infections.

2. If pandemic measures like masking fall, there is not much of a surprise that respiratory infections like COVID-19, RSV, and flu would see an increase, since they all can spread in the air, and in crowded environments. And they did in many countries, including the US ([US RSV Surveillance Data]). However, in a study that looked more closely into cohorts of children with and without prior infection with COVID-19, researchers showed that those with prior COVID-19 infection had doubled the risk of an RSV infection compared to those without prior COVID-19 infection, suggesting prior COVID-19 is a risk factor for RSV infection, especially in children [16]. 

3. Research also indicates that although children sometimes seem able to rapidly clear SARS-CoV-2, and appear to have milder initial infection, longitudinal analysis of data suggests that they are less likely than adults to harbor memory t-cells,which may not only compromise their cellular immunity, but also their ability to resist reinfection [15]. 

4. Together these studies indicate that infection from COVID-19 does not prevent reinfection, does not have a health benefit, can make the immune system weaker, and thus could likely play a role in the increases and severities of other illnesses including RSV and flu.

Immunity Debt

1. The “immunity debt” hypothesis suggests that immune systems will be more protected from future infections by being infected by viruses, and that preventing infections leads to a vulnerability to future infections. 

2. The phrase "immunity debt" was first used in a 2021 opinion paper [Worms Exhibit 1a], which suggested that the lack of exposure to certain viruses could lead to higher numbers of cases in the following years. This hypothesis proposed that pandemic measures implemented in 2020 had prevented immune systems from being exposed and stimulated as usual, and thus made them more vulnerable. To be considered scientifically valid, a hypothesis must be able to explain existing evidence and be supported by specific studies. There is no evidence presented in this opinion paper, nor has there been in any study since, showing that the existing data on RSV, flu, or COVID-19 is explained by the “immunity debt” hypothesis. 

3. Not only does this “immunity debt” hypothesis forgo providing any scientific studies, historical data also does not support it. RSV has not shown up more severely in places that had lockdowns versus those that did not. For example, in Sweden, where no lockdowns or mandatory masking happened, they still had exceptionally large RSV outbreaks [17]. Also, in the U.S., this is the second year in a row that RSV cases and the flu have surged in both prevalence and severity (as seen in US RSV Surveillance Data for hospitalizations). If prior infection with RSV meant future immunity to it, we would expect less cases this year after a surge last year, and with less severity. We saw the opposite (see Spaghetti Section). 

4. RSV and COVID-19 infections do not provide extended immunity.

5. RSV infection immunity is known to wane very rapidly over time, they have short-lived antibodies, and thus reinfections are common in subsequent seasons, and can even be seen in the same season [19]. 

6. The severity of RSV infections has been found to be related less with prior infection, and more to the immune response mounted by the host, including their T-cell-specific immunity. Anti-RSV antibodies are short-lived [18] and virus-specific memory cell responses are surprisingly absent after RSV infection, giving RSV the ability to cause recurrent symptomatic infections [30].

7. These studies indicate that the severity of RSV infections has little to do with prior infection, and more to do with the host’s innate immune response, including T-cell-specific immunity [18], which studies have shown is part of the immune dysfunction seen from COVID-19 infection [1][2][3][4].

8. COVID-19 reinfections have become commonplace, and each reinfection results in higher risks for significantly worsening health outcomes [12]. This goes against the idea that more infections strengthen the immune system.

9. A study on the antibody resistance profile and viral receptor binding affinity of SARS-CoV-2 Omicron BQ.1, BQ.1.1, XBB, and XBB.1 sub variants showed that these sub variants were barely susceptible to neutralization by sera from vaccinated individuals with or without prior infection, including persons recently boosted with the new bivalent (WA1/BA.5) mRNA vaccines. The study’s authors state, “The extent of the antigenic drift or shift measured herein is comparable to the antigenic leap made by the initial Omicron variant from its predecessors one year ago” [21]. Since the variants can quickly evolve (especially when methods to slow transmission such as masking are not being used) immunity acquired from vaccination or past exposure is not stopping infection. Thus, contrary to the "immunity debt" hypothesis, exposure is not preventing reinfection from COVID-19. 

10. The idea that immunity requires "exercise" or else it deteriorates, is not accepted or demonstrated scientifically. 

11. On the contrary, infections and reinfections with viral diseases have been tied to immune system and organ damage, as well as the development of new or worsened health conditions [11][12][13]. 

12. Research has also debunked the “hygiene hypothesis”, showing that when it comes to viral exposure, infection with viruses (such as the flu or RSV) does not lower a child’s chances of developing health issues like allergies later in life, and, on the contrary, is tied to worsened health outcomes– such as an increase in developing asthma. Avoiding viruses that make one sick by using good hygiene practices not only protects our health, it also helps stop the spread of many infectious pathogens in the community [22][70].  

The Spaghetti

1. There was an increase in RSV detections and RSV-associated emergency department visits and hospitalizations in multiple U.S. regions in "this year" season (2022-2023), with some regions nearing seasonal peak levels as early as November 2022 [18]. 

1. RSV-NET Interactive Dashboard | CDC [23] 

Image A: RSV-Associated Hospitalizations Sky-Rocket this Season, 2022-2023. The green dotted-line (this year)shows the early and steep 2022-2023 surge in RSV hospitalizations. The solid green line (last year)(2021-2022) also had an early start, but not nearly as steep as this year. 2020 (the blue square-dotted line) shows the incredibly low cases when measures to stop COVID were being taken en masse, revealing their effectiveness. 

1. On November 14th, 2022, the Children’s Hospital Association and the American Academy of Pediatrics urged the White House to declare an emergency to support the national response to the alarming surge of RSV combined with increasing flu circulation that are pushing some hospitals to the breaking point, citing: “Across the country, more than three-quarters of pediatric hospital beds are full, and many states are reporting more than 90 percent of their pediatric beds are occupied.” [24] Many hospitals had zero pediatric beds available, and sick babies and children are being sent out of state, and far from their families for care [25].

B. Weekly U.S. Influenza Surveillance Report | CDC [26]

Image B: Weekly Influenza Surveillance Report: The red triangle-dotted line shows an early 2022-2023 surge in influenza-like illness (ILI) outpatient visits. The orange line (2021-2022) was not nearly as steep and did not reach 2022-2023 ILI levels even at its peak in February. 2020-2021 (the pink line) shows the record-low cases compared to both the past and future years when measures to stop COVID were being taken en masse, again making a compelling case for their use to knock out other viruses on top of COVID-19 to prevent unnecessary illnesses and deaths.

1. COVID-19 cases and hospital admissions surged after Thanksgiving 2022 [27]—up 27% from the prior week, showing real time effects of gathering indoors unmasked, as well as travel without mask mandates, and transmission maps showed high levels of COVID-19 across the US [28]. 

C. Covid in the U.S.: Latest Maps, Case and Death Counts - The New York Times[27]

Image C: COVID in the US: Focusing on the red bar graphs’ heights to the right, you can really see the peak in late November 2022 (this occurred right after Thanksgiving), and its effects in 14-day change, with a 53% increase in test positivity, and more than 25% jump in hospitalizations that have been seen in all but 4 states. Although it is noted that cases are lower than last year, the number of people testing and number of tests actually being reported are vastly lower than last year as well, meaning we are flying blind but what we can see is a significant surge, and its relationship to holiday gathering. 

Long-term immunity due to prior infection with flu, RSV, or COVID-19 has not been shown in the historical data, but the effectiveness of using COVID precautions has been. It is important for the media and health organizations to recognize these basic observations, along with the aforementioned studies on COVID-caused immune dysfunctions, because they affect public perceptions and behaviors. Instead, what we are seeing is a predominance in the media of, well, worms.   

The Worms:

Immunity debt has been presented in recent media and press releases to suggest that people are better off being exposed to viruses in order to strengthen immunity; or stated another way, that humans who are NOT exposed to viruses could have damaged immune function. There is no scientific support for this hypothesis, or in what we know about the immune system. Yet, there is an increasing trend in the media to convey it as such, and to tie it to increasing incidences of flu, RSV, COVID-19, and influenza-like illnesses. Let's take a closer look.

Worm #1: CNN writes: “The pandemic behaviors created an ‘immunity gap’ or ‘immunity debt’ that makes more people in the US vulnerable to diseases like RSV.” (CNN, [Worms exhibit 2b]) 

1. Counter to this sentence, as stated above (Section: Weighing the Evidence), there are no studies that support the idea of an immunity debt, aka that preventing infections makes people more vulnerable to diseases like the flu or RSV. The evidence shows quite the opposite: COVID infection can damage the immune system and cause increased susceptibility to other diseases [1][2] [3] [4] [12] [29], and this is consistent with the observed large number of cases.

Worm #2: The Hill writes in discussing the current RSV outbreak: “Now that most children are back in daycare and school at a time when masking is less widespread, RSV has had the opportunity to spread among children whose immune systems have never encountered the virus before. This phenomenon has been described as “immune debt” due to pandemic prevention measures. The first time the immune system encounters a virus, symptoms of infection can be more severe as the body is learning to fight the virus, while subsequent infections tend to cause minimal or mild symptoms as the body now has a template to target the virus effectively.” (Worms The Hill, [exhibit 3c])

1. This statement is true for some diseases, but it does not apply to RSV. RSV immunity is short-lived [19] [30]. Reinfections are common, with some even occurring in the same season and, more commonly, the following season. The severity of these infections is related less to prior infection, and more to the host's cellular immune response [19]. 

2. Although there is a plethora of data and studies showing COVID-related damage to the immune system, there is no mention of this in the article. Exclusion can also be a form of mis- and disinformation.

Worm #3: CDC Newsroom Transcript Quote: “You know, in the previous years, atypical presentations of atypical seasons, due to mitigation against COVID left a large swath of the United States population uninfected. So we’re seeing more RSV because in the last two years, we’ve not seen infections in children as we have previously. And so these children, if you will, need to become infected to move forward because it’s a disease very common in children” ([Worms exhibit 4d]).

1. Counter to this sentence, as stated above (Section: Weighing the Evidence), there are no studies that support the idea that preventing infections makes people more vulnerable to diseases like the flu or RSV or that being infected makes them less vulnerable. 

2. Moreover, as stated above, RSV immunity wanes quickly [19]. In addition, even countries that used very few pandemic measures are still seeing surges in RSV cases this year (2022) [17]. 

3. Children do not need to become infected to “move forward.” RSV was responsible for many preventable infections, hospitalizations, and deaths in the past, but it does not need to be this way going forward, nor does it need to be increased due to immune damage from COVID-19. We can see in historical data, the tools we have do work to stop both RSV and COVID-19 (see Spaghetti section graphs). RSV infections are also tied to the development of asthma and can worsen other heart and lung conditions [29]. 

4. Delaying RSV infections is also beneficial, since older children typically have more developed immune systems to better fight RSV, whereas young children tend to get sicker from flu and RSV than other age groups, and infants younger than 6 months old stand to suffer the most, with nearly double the risk of RSV-related death compared to older children [20]. Therefore, preventing and delaying viral exposure is beneficial. 

5. The evidence shows COVID-19 infection frequently causes immune damage, which can cause increased susceptibility to other diseases, and this is consistent with the observed large number of cases and worsened severity of flu and RSV [1] [2] [3][4] [12][29].

Worm #4: CDC Newsroom Transcript Quote: “So we’re talking about it now, because people have a lot of questions. We want to answer the questions that are out there and reassure the American public that there are ways to prevent this. And that is prevented just by taking the vaccine for COVID. And for influenza, and that we have ways of preventing RSV infection by washing your hands avoiding contact. And if family wishes, they can use masks. But those are the reasons why we’re talking about it.” (Worms Exhibit [4d]).

1. COVID-19 infections are not suitably prevented by using only one prevention tool or notably “just by taking the vaccine”. The most recent bivalent mRNA vaccine boosters protect against symptomatic infection in 40% to 60% of cases, meaning that even when vaccine protection is at its most potent, about a month after getting the shot, people may still be quite vulnerable to breakthrough infections if using this tool alone.  Another recent study shows vaccines offer very little protection against long COVID [31]. 

However, vaccines are still recommended, as they tend to reduce hospitalizations from the acute phase of COVID-19 infections and show many benefits over being unvaccinated [32].  

With vaccine efficacy and booster take-up waning, and the variants evolving, the amount of protection offered by vaccines is helpful but not sufficient on its own, and a multilayered approach is necessary [33] [34] [35].

1. Masking should be emphasized as a major preventative action, not as a side note. The CDC speaker said influenza and RSV (both viruses that are commonly spread through the air) can be avoided just by washing hands and avoiding contact, and then gave a very optional statement afterwards about masking. Since all of these diseases are spread through the air, masking is the best tool we have, and should be highlighted as such. Studies have shown well-fitted respirator masks significantly reduce risk of COVID-19 infections [49] [50] [51]. They also show that places with mask mandates have significantly fewer viral infections compared to those with masking optional policies [52].

The Meatballs (or Juicy Vegetables Depending on Your Preferences):

Meatball/Veg #1:It is well-established in the scientific literature that COVID-19 infection can cause significant short-term and long-term damages to the immune system and increased susceptibility and risks of contracting other viral infections.

1. Prior COVID-19 infection is a risk factor for RSV infection. A recent 2022 study showed that among RSV-infected children aged ≤5.0 years, the RSV-positive children had significantly greater health determinants and comorbidities, including preterm births, immunological diseases, and chronic pulmonary disorders of perinatal origin, which increase RSV contract risks. The study also showed RSV-positive children had a significantly greater prevalence of previous SARS-CoV-2 infections (19%) [56].

2. Evidence is emerging that COVID can cause dysregulation of critical immune cells known as T-cells, which can be prematurely aged through infections with SARS-CoV-2. Not only can these T-cells then lead to unrecognized organ damage, but the exhaustion of those hyperactivated T-cells means they may be less able to guard against other pathogens [2] [57], including but not limited to viruses like influenza and RSV. Infants in particular may be especially vulnerable to more serious RSV infections due to immaturity of the immune system and the fact that passive transfer of maternally-transmitted antibodies likely has an immunosuppressive effect [19]. 

3. Even mild infections with COVID-19 can lead to long-term immune system damage and dysfunction [48] [58]. It is known that in older adults, changes in the immune system and particularly cellular immunity lead to increased susceptibility to RSV [59]. Immune damage and dysfunction have been noted to happen after COVID-19 infection in individuals from a variety of ages making them more vulnerable to other infections due to dysfunction of cellular immune function [48]. A recent Nature study found that even when initial COVID-19 infection was considered mild, immune damage and dysfunction remained persistently high at least 8 months after infection [2].

Meatball/Veg #2: If you have had COVID-19 before, you have even more reason to use preventatives to avoid reinfections. 

1. Immunity gained from infection or vaccination does not give long-term protection from reinfection from COVID-19[35].

2. Reinfections by COVID-19 cause greater likelihood of health damage, both short-term and long-term, including, but not limited to, damage to the immune system, and greater susceptibility to future infections from other pathogens as a consequence [1] [2] [3] [4] [12].

3. Coinfections with COVID-19 and flu or RSV have significant negative health outcomes [8][9]. 

Meatball/Veg #3: Protective measures work together to prevent infection. If you don’t catch COVID-19, flu, and/or RSV, your body stays stronger.

1. Increased prevention strategies can help protect against infection by reducing exposure to infectious viruses, and reduce chances of developing immune system and organ damage, as well as the development of new or worsened health conditions [11][12] [13]. 

2. When it comes to viral exposure, infection with viruses (such as the flu, RSV, and COVID-19)) does not lower one’s chances of developing health issues [70]. 

3. Avoiding viruses and microbes that make one sick by using good hygiene practices not only protects health, it also helps stop the spread of many infectious pathogens in the community [22].  

The Cannoli

The jury is in: There is a large amount of evidence that supports COVID-19 as a major causal factor in the recent surges in cases and severity of RSV, influenza, and flu-like illnesses, whereas the "immunity debt" hypothesis remains unfounded in studies, historical data, and in the current scientific knowledge-base. 

Current SARS-CoV-2 variants are highly immune evasive [36], every reinfection causes greater likelihood of damage, not only to the immune system, but to many body organs and systems. The result is an increase of diseases that are often associated with increased susceptibility to and/or worse outcomes from viral infections, whether it be the flu, RSV, COVID-19 [12] [16] [37] [68], or other infectious diseases– such as cases of scarlet fever that were rising in the U.K in December 2022 [38].

Very important, as discussed above, is that the increase in both size and severity of RSV and flu infections cannot be explained by changes in pandemic measures alone. This is shown in historical data, in the spaghetti section in the differences in the US cases and hospitalizations data, notably between the 2021 (year without mass pandemic measures and mandates) and 2022 (second year as such) years with increase in both cases in severity. COVID infections have been tied to increase in other infections, including those with RSV, with one study showing an increase by a factor of 2 [16]. It is shown in the case of New Zealand (discussed in Weighing the Evidence), that there was no matching increase in severity of RSV cases seen in a population without high prior COVID-19 exposures. 

The immunity debt hypothesis is unfounded and is often misused and misunderstood in a way that could cause greater harm. Yet, it is being placed in a loud-speaker position in the headlines, and health authorities have also mentioned it in press releases. There is much confusion in the media, in the public, and even amongst healthcare practitioners due to this misinformation, that has led people to fear the use of the tools that have the most potential to protect them from both short-term and long-term immune damage, viral infections, and negative health outcomes of long COVID and repeat infections. The flagrant projection of such an unfounded hypothesis as "immunity debt" by the media and health organizations when the stakes are so high raises the suspicion that this is not just misinformation, but disinformation – which is intentional misinformation given for political and/or economic gain. 

It is inappropriate and misleading to relay a message that not only goes directly against the scientific evidence and consensus on how to end COVID-19 as a public health threat [39], but also that can result in actions that bring significant short-term and long-term harm to individuals and the public as a whole. 

The only way to combat such disinformation is to relay the research to the public and point out the worms. Perhaps we can use them one day to catch the big fish that are behind all of this. In the meantime, we can at least enjoy a worm-free meal: Skyrocketing cases of flu, RSV, and COVID-19 can be curbed by using preventatives such as wearing N-95 mask equivalents or better, implementing purification/ventilation strategies to reduce airborne transmission, using testing and isolating strategies to reduce spread, using social distance and avoiding crowded spaces, and by staying up-to-date on vaccinations to reduce risk of severe acute illness symptoms and hospitalizations. Multilayered prevention is key. Bon Appetit! 

The Doggy Bags

Some take-home selections from each section:

Doggy Bag 1: RSV and COVID-19 Viral Infections, Co-Infections, and Effects

1. Studies have shown that expectant mothers diagnosed with COVID-19 are around 40 percent more likely to deliver prematurely [40][41], and that preterm infants are diagnosed with RSV at higher rates and worsened severity of infections both in infancy and in early childhood [42], providing further evidence for COVID-19-related increases in RSV cases and severities in infancy and early childhood.  

2. Current surges of RSV hospitalizations have been seen across all ages, including 10 times higher rates amongst seniors ages 65+, 5 times higher for 1-4 year olds, and 7 times higher amongst infants 6 months and younger [23]. 

3. RSV infections are also tied to the development of asthma and can worsen other heart and lung conditions [29]. Infants younger than 6 months old stand to suffer the most, with nearly double the risk of RSV-related death compared to older children [20]. Because infants under the age of 6 months and premature infants are particularly susceptible to RSV, it is extremely important to protect them from potential exposure to this virus. 

4. Studies indicate that you can be infected with both the flu and COVID-19 at the same time, that being infected by one may increase risk of being infected by the other, and that viral coinfections can significantly increase the susceptibility of patients to severe disease and can result in more serious damage to the immune system than in those without viral coinfections [9],[10],[43]. 

Several literature reviews have investigated coinfections of SARS-CoV-2 with other respiratory pathogens, such as RSV. One study that analyzed 32 pediatric patients under 2 years old who were hospitalized with COVID-19 found that 18.7% of cases were coinfected with RSV. Those patients required a significantly longer length of stay. Another study among 250 patients diagnosed with COVID-19 detected RSV in 4.8% of the patients and showed patients coinfected with viral pathogens had longer hospital stays than patients coinfected with atypical bacterial pathogens [43]. 

Furthermore, a systematic review of over 100 articles showed as many as 19% of patients with COVID-19 had coinfections, and 24% have superinfections, both of which were associated with poorer outcomes, including increased risk of mortality [9].

And finally, in a study of 48 COVID-19 patients (29% ICU and 71% non-ICU) there was evidence of coinfections in 34 COVID-19 patients (71%) with Influenza A being the most common, and to which a direct relationship with mortality was seen [10]. It is apparent in the research that infections are NOT providing any strengthening of the immune system, but in many cases are making people more susceptible to coinfections and worsened outcomes. 

Doggy Bag 2: Influenza-like Illness

1. In the fall of 2021, the percentage of positive flu tests was split almost equally between influenza A and B. This year, almost all of the positive flu tests have been for influenza A [18]. This is important because researchers have found that infection with influenza A may increase a person’s susceptibility to COVID-19 by increasing the amount of ACE2—the receptor that allows the virus to infect our cells—in the lungs, thus increasing the odds of getting COVID-19 and the risk for severe illness [45]. 

2. COVID prevention strategies help stop flu, RSV, and other illnesses.

3. Infections from RSV, the flu, and SARS-CoV-2 spread through close contact with an infected person, as well as through the air and contaminated surfaces, entering our bodies through the eyes, nose, and mouth [29][46].

4. Risk reduction measures against COVID-19 also work against flu and RSV infections [29][46]. Mask wearing, social distancing, increased ventilation and purification, and hygiene practices such as hand-washing and disinfecting surfaces can help protect from all three viruses [47]. 

5. As seen in Spaghetti Section Images A and B above, in the winter of 2020, when these protective measures were more common, the U.S. saw an overall drop in non-COVID respiratory infections, an almost nonexistent flu season, and reduced hospitalizations for RSV.

Doggy Bag 3: COVID-Related Immune Damage

1. COVID-19 infections cause cardiopulmonary disease and immune dysfunction [1][2] [12]. These are major risk factors for hospitalization and mortality in children and adults of all ages who are infected with RSV, and helps explain why we have been seeing not only more cases, but also worsened severity of RSV infections in the population.  

2. Even mild infections with COVID-19 can lead to long-term immune system damage and dysfunction[48]. 

3. Studies indicate an ongoing, sustained inflammatory response following even mild-to-moderate acute COVID-19 [1][2].

Doggy Bag 4: Masks Work and People Don't Mind Wearing Them When Directed to for their/each other's Health and Safety 

1. Studies have shown well-fitted respirator masks significantly reduce risk of COVID-19 infections [49] [50] [51]. They also show that places with mask mandates have significantly fewer viral infections compared to those with masking optional policies [52]. 

2. Some countries are calling for a return to masking policies through either stronger recommendations and/or considering mandates [53]. 

3. In a November 2022 survey by Nanos Research, 7 in 10 Canadians support or somewhat support a return to mandatory wearing of face masks in indoor public places this past fall if authorities deem it necessary due to rising COVID cases, while three in ten are opposed or somewhat opposed [54]. This shows the importance of calling out health authorities who are not using the research and data to give strong, clear, loud recommendations to the public to wear well-fitted, high-quality respirator masks in public spaces.   

Doggie Bag 5: Preventative Measures

1. COVID-19 continues to pose a serious threat to the public [39].

2. Studies have shown well-fitted respirator masks significantly reduce risk of COVID-19 infections [49] [50] [51]. 

3. 50% of the spread is from people not having any outward symptoms of infection (asymptomatic), so masking cannot only be done when sick[60][61][62]. Proper masking should be done in any public places where multiple households are interacting without sufficient prior testing/isolation periods. A well-fitted respirator mask, such as N95, provides significantly more protection than surgical and cloth masks and should be used when possible [49] [50] [51]. 

4. Places that mandate masks have lower COVID infections and places that take away mask mandates result in a significant increase in COVID-19 infections [52]. 

5. Using masks, distance, good hand sanitation, and ventilation/purification, reduces chances of infection from RSV, flu, and COVID-19 [49] [50] [51]. 

6. Staying up-to-date with vaccinations reduces chances of hospitalizations from the initial acute phase of COVID-19 infection [32].

7. Testing and isolation reduce the chances of transmitting contagious diseases to others [63] [64]. 

8. The scientific consensus supports wearing a high quality, well fitted mask, and using other preventative measures to reduce the risks of COVID-19 to your health and the health of the community [39]. 

9. Avoiding crowded environments and using social distance reduces chances of infection [65].

10. Using only a single COVID-19 Rapid Antigen Test (RAT) result as a screening tool for being negative is very limited due to lower accuracy in picking up the newer variants [66]. A negative RAT result is not sufficient in ruling out COVID-19 infection. Serial testing and/or use of molecular PCR tests reduce this risk of false negatives [63] [64] The take-home message is that testing is only one layer in a multilayered approach and should not be counted on alone as a prevention tool.

11. Definitely, when experiencing symptoms from any of the above illnesses (most of which have overlapping symptoms), stay at home to avoid spreading diseases to others outside your household. In addition, studies support a 14-day isolation period to prevent transmission of COVID-19 to others [61]. If residing with others, take extra actions such as room isolation and increasing ventilation/purification to reduce exposure to household members. 

The Sources

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Worms Exhibits:

1. Immunity Debt Opinion Paper: Cohen R, Ashman M, Taha MK, et al. Pediatric Infectious Disease Group (GPIP) position paper on the immune debt of the COVID-19 pandemic in childhood, how can we fill the immunity gap? Infectious Diseases Now. 2021;51(5):418-423. https://doi.org/10.1016/j.idnow.2021.05.004 

2. CNN: Christensen J. Pandemic “immunity gap” is probably behind surge in RSV cases, scientists say. CNN. Published October 26, 2022. https://www.cnn.com/2022/10/26/health/rsv-immunity-gap/index.html 

3. The Hill: Dr. Priya Edward. Immunity debt: Why so many kids are sick with RSV. The Hill. Published November 3, 2022. Accessed December 13, 2022. https://thehill.com/opinion/healthcare/3718449-immunity-debt-why-so-many-kids-are-sick-with-rsv/ 

4. CDC Newsroom: CDC. Published January 1, 2016. Accessed December 13, 2022. https://www.cdc.gov/media/releases/2022/t1104-update-respiratory-disease-circulation.html 

5. Hatter L, Eathorne A, Hills T, Bruce P, Beasley R. Respiratory syncytial virus: paying the immunity debt with interest. The Lancet Child & Adolescent Health. 2021;5(12):e44-e45. doi:10.1016/S2352-4642(21)00333-3 https://www.thelancet.com/journals/lanchi/article/PIIS2352-4642%2821%2900333-3/fulltext 

Media Sources that Combat Worms 

1. Newswise
   There is no evidence that “immunity debt” is real, however, the end of COVID-19 mitigation efforts means a higher risk for viral infections. www.newswise.com. Accessed December 14, 2022. https://www.newswise.com/factcheck/there-is-no-evidence-that-immunity-debt-is-real-however-the-end-of-covid-19-mitigation-efforts-means-a-higher-risk-for-viral-infections/?article_id=782293 

2. Forbes: Lee BY. Are “Immunity Debt” Claims After Covid-19 Precautions Accurate Or Misinformation?. Forbes. Accessed December 14, 2022. https://www.forbes.com/sites/brucelee/2022/11/13/are-immunity-debt-claims-after-covid-19-precautions-accurate-or-misinformation/?sh=7660f6037348 

3. Global News : “Immunity debt”: Why experts say this new term promotes COVID-19 “misinformation” - National | Globalnews.ca. Global News. Accessed December 14, 2022. https://globalnews.ca/news/9272293/immunity-debt-covid-19-misinformation/ 

4. Infection Control Today: Respiratory Spread and the Flawed Concept of Immunological Debt: A New Understanding. Infection Control Today. Accessed December 14, 2022. https://www.infectioncontroltoday.com/view/respiratory-spread-flawed-concept-immunological-debt-new-understanding