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COVID Critical: Complacency and Consequences in an Unfinished Pandemic
- Heather McSharry, PhD
- Jun 25
- 32 min read
Updated: 1 day ago
Summary
As the world turns its attention elsewhere, SARS-CoV-2 continues to evolve—quietly, globally, and in ways that may matter more than most realize. In this episode, Heather digs into the World Health Organization’s latest data on rising COVID-19 activity in 2025, explores the emergence of new variants like NB.1.8.1, and examines the troublingly low global vaccine uptake. From shifting viral landscapes in the Eastern Mediterranean and South-East Asia to the quiet complacency taking root in higher-income nations, we connect the dots between surveillance, science, and public response.
Listen here or scroll down to read full episode.
Full Episode
In a hospital corridor in Bangkok, a nurse adjusts her mask before checking the vitals of a coughing patient. Half a world away, in a wastewater monitoring lab in Ohio, a technician sees a faint rise in viral fragments. In Riyadh (ree-ad), Singapore, São Paulo, whispers a virus, too quiet to make headlines but loud enough for those who listen closely.
There’s no lockdown. No breaking news. Just a slow climb in the numbers—and a virus that continues adapting.
Variants shift. Immunity fades. And somewhere between apathy and adaptation, SARS-CoV-2 remains. Evolving quietly. Persistently. Globally. This is COVID Critical: Complacency and Consequences in an Unfinished Pandemic.
A Global Snapshot
OK, let's remind ourselves of some facts: COVID-19 is an infectious disease caused by the SARS-CoV-2 virus, which typically spreads between people who are in relatively close contact, through droplets and larger aerosols, and also over a bit longer distances through airborne transmission of smaller aerosols, especially in indoor, crowded, or poorly ventilated environments.
COVID-19 vaccines offer strong protection against severe disease and death. While it’s still possible to become infected with COVID-19 after vaccination, the illness is usually much milder or even asymptomatic in those who have been vaccinated. Despite what you've heard, don't expect sterilizing immunity from COVID vaccines or any other vaccines. It's not the right metric. Vaccines success mean serious illness and or death was prevented. For a deep dive into this topic check out my episode on sterilizing immunity.
OK, so according to the latest report from the World Health Organization, COVID-19 activity is once again on the rise. Sentinel surveillance data from 73 countries shows an average test positivity rate of 11%—matching the peak observed in July 2024. That’s up from just 2% reported back in February.
This surge isn’t happening everywhere — and that’s what makes it harder to track. Much of the rise is concentrated in hotspots across the Eastern Mediterranean, South-East Asia, and the Western Pacific. Meanwhile, Africa, Europe, and the Americas are reporting relatively lower test positivity rates, holding steady between 2% and 3%. And in places like the Caribbean and the Andean zone, the numbers are starting to creep upward, signaling potential trouble ahead.
So let's look a little closer at a regional rundown
Eastern Mediterranean: Countries like Saudi Arabia, Egypt, and Pakistan have seen test positivity jump to 15–17% in recent weeks — signaling active transmission.
South-East Asia: In Thailand, India, and the Maldives, test positivity has climbed from below 1% to 5% in just a month — a notable shift in pace.
Western Pacific: After a relatively calm winter, Hong Kong, Singapore, and China have returned to double-digit positivity, pointing to renewed community spread.
But here’s what’s notable: despite these regional surges, the U.S. has issued no COVID-specific travel advisories. No mandatory testing. No vaccination or masking requirements. No formal alerts. The infrastructure that once flagged global hotspots has largely gone silent—even when the virus hasn’t.
Still, travelers should tread carefully. Just because the U.S. isn’t warning about these trends doesn’t mean destination countries won’t have their own rules.
🛫 Check the public health websites or foreign ministries of your destination before travel. Some may require vaccination proof, testing, or insurance for COVID-related care. Don’t assume silence means safety. And seriously mask up in an airport or on a plane. Not just for COVID. Measles is going a little crazy right now too.
As for wastewater surveillance in North America and Europe? Still relatively low. But as we’ve learned, these signals can shift quickly. And what’s visible in the data depends entirely on whether we’re still looking.
What We Don’t See Anymore
Here’s the hard truth: we don’t really know how much COVID-19 is circulating in the United States right now. Not with the clarity we once had. Not with the consistency the virus still demands.
After the federal Public Health Emergency expired in May 2023, many of the systems we relied on—daily case counts, detailed dashboards, test positivity tracking—quietly faded. What remains is a fragile patchwork: a few sentinel surveillance networks, some hospital admissions data, and scattered wastewater monitoring. And even those are running quieter than before.
So when we say COVID-19 is “low” in the U.S., what we’re really saying is: our visibility is limited. We're all driving through fog with just a few working headlights—not a full windshield.
That said, we’re not flying totally blind. A few signals are still flickering:
The CDC’s Respiratory Virus Dashboard continues to publish weekly summaries on COVID-19, alongside flu and RSV. These offer insight into hospitalization and emergency room trends but who knows how long this database will be accurate.
HHS Protect, now maintained on HealthData.gov, this was a nice idea but no decent covid data are currently available.
The CDC’s Wastewater Surveillance Network also nice in theory but seriously limited data.
For variant watchers, CoVariants.org, in collaboration with GISAID Global Initiative on Sharing All Influenza Data, still tracks SARS-CoV-2 lineage activity—including the rise of NB.1.8.1—in U.S. regions.
And while updated less frequently, the CDC Variant Tracker still reports which strains dominate by region.
But the best resource for variant tracking is the Coronavirus Network (CoViNet), launched in 2024.
But these are seriously inadequate and in no way provide the real-time clarity we once had. Local health departments aren’t regularly publishing testing data. At-home results go unreported. Even clinical testing volumes have dropped sharply. By the time we detect a surge—through hospitalization or wastewater—the virus has already gained ground.
In that landscape, assumptions can be dangerous. Saying “COVID is low” without surveillance is like saying the forest is safe because no one sees fire—without realizing the smoke detectors have been turned off.
The WHO continues to recommend multi-layered surveillance for a reason. Without it, we risk mistaking absence of evidence for evidence of absence. In the U.S., we’re living inside that gap.
Houston: One City Still Looking
While most U.S. cities have dialed back or dismantled their COVID monitoring systems, Houston is one of the cities that has kept a light on. And what we see there is telling.
The Houston Health Department continues to track near-real-time SARS-CoV-2 wastewater levels across more than 30 treatment plants. Their data, spanning July 2020 through June 2025, shows the full pandemic arc: major waves during Delta and Omicron, recurring surges in 2023 and 2024, and—more recently—another upward shift.
In May and June 2025, wastewater concentrations began rising again in several locations: Southwest, Northwest, Northgate, and Almeda Sims, among others. While current levels haven’t reached previous peaks, these renewed red and orange tones on the heatmap show virus levels well above baseline—a striking signal when few cities are still measuring at all.
Why does this matter? Because wastewater doesn’t depend on individual behavior. It doesn’t require someone to book a test, or report an illness. It detects community spread whether people are paying attention or not. And in Houston, the virus is saying clearly: it hasn’t left.
Testing: Fewer Cases, But Rising Positivity
Houston Methodist, one of the city’s major health systems, offers another window.
Their long-term testing trend—from March 2020 through June 2025—charts familiar peaks, but also something subtle and significant: while the number of confirmed cases (shown in blue) remains relatively low this year, the positivity rate (the orange line) is climbing again.
As of June, their 7-day rolling average sits around 10%. In a low-testing environment, that’s not trivial—it’s a flashing light. Higher positivity with fewer tests often signals underdetection. And in a hospital-based testing cohort, it may mean people are only seeking care when they’re already quite sick.
The Bigger Picture
Together, Houston’s wastewater and testing data tell a story the national dashboards no longer do: SARS-CoV-2 is still present, still evolving, and still quietly rising—even if we’ve stopped looking for it.
WHO’s risk assessments continue to emphasize the need for multi-source, sustained surveillance. Because once that surveillance fades, we don't see the virus fade—we just see it later. The more we turn down the volume on COVID data, the more likely we are to miss the warning before the next wave builds.
Variants: An Evolving Landscape with Quiet Competition
Another thing to keep in mind...COVID-19 isn’t static. The virus continues to evolve in real time, reshaping not just its genetic profile, but also our understanding of what comes next.
As of early June 2025, two subvariants are locked in a close race across the U.S.: LP.8.1 and NB.1.8.1. According to the CDC’s genomic surveillance (covering the two-week period ending June 7), LP.8.1 still leads at 38% of sequenced cases—but NB.1.8.1 is close behind at 37%, surging from just 2.5% in April. Globally, NB.1.8.1 is rising fast across the Western Pacific, the Americas, and Europe.
What is NB.1.8.1?
Nicknamed “nimbus” by some labs, NB.1.8.1 is a descendant of XDV.1.5.1, which in turn emerged from JN.1, a descendant of the Omicron lineage, specifically the BA.2.86 subvariant also known as Pirola that was discovered in the summer of 2023. What makes this variant noteworthy isn’t just its growth—it’s the mutation profile:
T22N, F59S, G184S – common in immune-evasive lineages
A435S – linked to reduced neutralization by Class 1 antibodies
V445H – improves binding to the ACE2 receptor (more transmissible)
T478I – enhances antibody evasion
1. T22N (Threonine → Asparagine at position 22)
What changed: Threonine (T), a polar amino acid, was replaced by Asparagine (N), another polar amino acid near the N-terminal domain (NTD) of the spike protein.
Why it matters: This mutation is commonly seen in immune-evasive variants. Subtle structural changes here may alter how antibodies bind to the spike protein, helping the virus partially evade immune detection.
2. F59S (Phenylalanine → Serine at position 59)
What changed: Phenylalanine (F), a bulky, hydrophobic amino acid, was replaced with Serine (S), which is small and polar, also in the N-terminal domain.
Why it matters: This swap alters the local shape and charge, potentially affecting how neutralizing antibodies recognize the spike. It's been noted in immune-evasive strains.
3. G184S (Glycine → Serine at position 184)
What changed: (G), the smallest and most flexible amino acid, was replaced by Serine (S), which introduces a side chain, likely at or near receptor-binding domain (RBD) boundaries.
Why it matters: This can impact protein folding or surface structure, again aiding immune evasion by subtly changing how antibodies “see” the spike protein.
4. A435S (Alanine → Serine at position 435)
What changed: Alanine (A), a small nonpolar residue, was replaced by Serine (S), a polar one, this is also within the RBD, closer to the ACE2 binding surface.
Why it matters: This mutation is associated with reduced binding of Class 1 neutralizing antibodies — one of the main antibody types generated after infection or vaccination.
5. V445H (Valine → Histidine at position 445)
What changed: Valine (V), a hydrophobic amino acid, was replaced with Histidine (H), which is larger and can carry a charge, directly in the ACE2-binding region of the RBD.
Why it matters: This mutation enhances binding to the ACE2 receptor, making the virus more efficient at infecting cells — and thus potentially more transmissible.
6. T478I (Threonine → Isoleucine at position 478)
What changed: Threonine (T), a polar residue, was replaced by Isoleucine (I), a nonpolar, bulky amino acid, also in the RBD, at a known epitope targeted by many neutralizing antibodies.
Why it matters: This mutation is associated with increased antibody evasion, helping the virus dodge immune recognition while maintaining its infectious ability.
Early pseudovirus studies (See WHO's risk evaluation PDF below) show only modest neutralization reduction compared to LP.8.1 (about 1.5 to 1.6-fold in plasma from people with BA.5 or JN.1 exposure). But in a world of waning immunity and low booster uptake, even small advantages can matter.
In an interview, Dr. Magdalena Sobieszczyk, chief of the Division of Infectious Diseases at New York-Presbyterian/Columbia University Irving Medical Center, said, “What sets NB.1.8.1 apart is how quickly it spreads. It has a genetic advantage: mutations that make it easy for it to bind to receptors on human cells. The mutations could allow NB.1.8.1 to spread faster and therefore infect more people.”
OK, so this variant is growing rapidly—but so far, it's not more severe. The virus is changing, but the tools still work. The challenge isn’t the virus outpacing our defenses. It’s us letting go of the systems that track it.
Here's the WHO's risk evaluation for Nimbus:
What We Know
As of now, the WHO classifies NB.1.8.1 as a Variant Under Monitoring (VUM)—but not a Variant of Concern. Why?
No evidence of increased severity: No spike in ICU cases or deaths
Vaccines remain effective: Mouse studies show LP.8.1 or KP.2-based vaccines still neutralize NB.1.8.1 effectively
No antiviral resistance detected
Still, WHO notes that surveillance gaps and limited data sharing may mask subtler risks. In the U.S., where clinical testing has collapsed and sequencing volume is down, we're flying with fewer instruments.
Bottom line: NB.1.8.1 may not be a game-changer—but it’s a momentum shift. Slightly more immune escape, slightly faster spread. And in a world that’s downgraded its watchfulness, that might be enough.
The Broader Variant Picture
Since the emergence of Omicron, SARS-CoV-2’s family tree has grown exponentially. Variants
like XEC, XFG, and XFC still circulate at lower levels, and new lineages are constantly appearing. Most fade—but a few stick.
To keep pace, WHO has expanded surveillance through the Coronavirus Network (CoViNet), launched in 2024. This system tracks variants not only in people, but also in animals and chronically infected individuals, who often serve as mutation incubators.
WHO also updated its variant classification framework in 2023, refining the criteria for:
Variants of Concern (VOC)
Variants of Interest (VOI)
Variants Under Monitoring (VUM)
The current top concern is still NB.1.8.1, though the public health risk is considered low for now.
The Takeaway
So when we say ‘COVID isn’t over,’ it’s not a rhetorical phrase—it’s an evolutionary fact. LP.8.1 is still holding the lead, but NB.1.8.1 is surging fast. This isn’t just about numbers; it’s about mutations. And the question we have to keep asking is: Are we still watching?
Vaccines—A Stalled Shield
Now, unfortunately, despite the clear scientific consensus that vaccines prevent severe disease and death, global uptake—especially among high-risk populations—has stalled. In 2024, only 1.68% of older adults and 0.96% of health workers had received a COVID-19 vaccine dose across reporting countries. The disparity is stark: higher uptake in Europe (5.1%) and the Americas (3.6%), but less than 0.5% in low-income countries. And even in high-income countries, many remain unboosted. In the US, despite availability, though that is getting tanked here too, uptake of updated boosters remains under 20% among older adults.
When it comes to COVID-19 vaccination in the United States right now, the word that best describes the landscape is: patchy. According to the CDC’s most recent data from April 26, 2025, vaccination coverage among adults 18 and older remains low—and uneven. Nationwide, the range spans from just over 6% to about 42% of adults reporting they’ve received the updated 2024–2025 COVID-19 vaccine.
On the map, you’ll see deeper shades in parts of the Northeast, Midwest, and West—places like New York City, Illinois, and Colorado—where coverage tops 29%. But across much of the South and Mountain West, coverage rates barely crack 17%. And in some areas, there isn’t even enough data to report—an absence that speaks volumes about shrinking surveillance.
So how does this compare to last season? Not great. In most of the country—especially in the Midwest, Southeast, and parts of the Northeast—vaccination coverage has actually gone down compared to the 2023–2024 season. That’s shown in orange on the CDC’s map. Only a handful of states saw increases, and even those were modest.
These data come from the National Immunization Survey–Adult COVID Module, a weekly mobile phone survey. It’s self-reported, and it’s subject to sampling limitations. But it’s still one of the best tools we have for understanding vaccine uptake across the country. And the picture it paints is clear: most adults aren’t getting the updated shot.
That drop matters. Because even as the virus evolves, updated vaccines remain one of the most effective tools to reduce severe illness, hospitalizations, and long COVID. But when coverage falls—and falls quietly—we lose one of our best lines of defense. The reasons behind the drop are complex: vaccine fatigue, misinformation, limited access, or a general sense that the threat has passed. But the risk hasn’t gone away. It’s just harder to see.
In the absence of strong public messaging or robust infrastructure to get vaccines where they’re needed most, coverage gaps widen. And for a virus still evolving, those gaps are where it finds its openings.
This means that delaying a booster while waiting for a variant-specific shot may feel strategic, but don’t wait. Any protection is better than none.
And part of the problem with vaccine uptake is that people hear a lot of bullshit about vaccines and it's just as bad for COVID vaccines. So, that brings us to
WTF-RFK
The segment in which I set the record straight on the lies rfkjr has spewed about vaccines.
In a series of interviews in April 2025, U.S. Health and Human Services Secretary rfkjr lied about the safety and necessity of COVID-19 vaccines for children. In his letter justifying removing healthy pregnant and women from the recommended COVID vaccine schedule he lied further:
He claimed the CDC’s recommendation for vaccinating children was “always dubious” because kids “had almost no risk for COVID-19.”
He asserted that most children had no reason to be vaccinated, stating:
“Why are we giving this to tens of millions of kids when the vaccine itself does have profound risk?”
He linked the vaccine to “huge associations” with myocarditis, pericarditis, strokes, neurological injuries, and added:
“We’re seeing a lot of adverse events from the vaccine, particularly in children.”
He also alleged that Pfizer’s clinical trial showed 25% more deaths in the vaccine group than in the placebo group.
Pregnant women have higher rates of fetal loss, preterm birth, and placental blood clotting after getting the covid vaccine.
He removed healthy pregnant women and children from CDC COVID vaccine recommendations meaning insurance, Medicaid, and Medicare won't have to cover them anymore.
It's all bullshit. Let's look at the data and first we're going to hear what other experts say about it.
Dr. Sean O’Leary
Chair, AAP Committee on Infectious Diseases
On vaccine safety:
“The vaccines are very safe in kids.”
On COVID risk in children:
“COVID was in the top 10 causes of death among children… and many of those deaths were in healthy children.”
He clarified that while the risk of myocarditis/pericarditis is real, it is rare and mostly affects adolescent males after the second dose—and the rate is very low for younger children.
Dr. Jeffrey S. Morris
Director of Biostatistics, University of Pennsylvania
Called RFK Jr.’s death-rate claim from Pfizer trials statistically invalid:
“There is no statistical evidence that vaccinated had higher death rate than placebo in the Pfizer phase 3 trial at all.”
Clarified that while there are some vaccine risks, the relevant comparison is to the risks from COVID-19 infection:
“A non-negligible proportion of children are hospitalized with COVID-19… and some suffer long COVID or post-infectious inflammatory syndromes (MIS-C).”
On strokes and neurological injury claims:
“I have not seen any evidence that COVID-19 vaccines increase the risk of stroke or cause neurological issues in children.” Studies from Pediatrics and JAMA Pediatrics found no safety signal.
Charlotte Moser
Children’s Hospital of Philadelphia, ACIP Member
Emphasized that vaccine-associated myocarditis is less severe than myocarditis caused by COVID-19:
“No children have died from vaccine-related myocarditis, but some have died from infection-related myocarditis.”
Noted that the risk of severe complications from the virus persists, especially for the newly born population:
“Every year, 3 to 4 million new susceptibles are born… Vaccination gives us control over how they gain immunity. Infection leaves it to chance.”
Dr. Steven Fleischman
President of the American College of Obstetricians and Gynecologists,
Released a statement on behalf of the American College of Obstetricians and Gynecologists or ACOG on May 27th, in which he said “the science has not changed. It is very clear that COVID infection during pregnancy can be catastrophic and lead to major disability, and it can cause devastating consequences for families. The COVID vaccine is safe during pregnancy, and vaccination can protect our patients and their infants.”
“In fact, growing evidence shows just how much vaccination during pregnancy protects the infant after birth, with the vast majority of hospitalized infants less than six months of age – those who are not yet eligible for vaccination – born to unvaccinated mothers,” Fleischman added.
Summary: Fact vs. Misinformation
Claim by RFK Jr. | Expert Response / Evidence |
Kids are “at almost no risk” from COVID-19 | Dr. Sean O’Leary (AAP): COVID-19 was a leading cause of death among children during the pandemic, including healthy children. Vaccination reduces severe outcomes. |
Vaccine causes “profound risk” | O’Leary, Moser: Myocarditis is rare, milder post-vaccination, and far less dangerous than COVID-related myocarditis. Risks are highest in adolescent males but remain very low overall. |
Linked to “strokes, neurological injuries” | Dr. Jeffrey Morris: “No evidence supports this.” Peer-reviewed studies (e.g., Pediatrics, JAMA Pediatrics) show no safety signal for stroke or neurological harm in children. |
Pfizer trial showed “25% more deaths” in vaccine group | Dr. Jeffrey Morris: “Statistically invalid.” The Pfizer Phase 3 trial showed no statistically significant difference in mortality. Claim is based on misinterpretation of data. |
CDC recommendation was “always dubious” | The CDC’s original guidance followed expert review of clinical trial and epidemiological data showing that COVID infection posed real risks to children, including healthy ones. |
“We’re seeing a lot of adverse events, particularly in children” | Real-world safety data (millions of doses): Adverse events are rare and mostly mild. No evidence supports widespread serious harms in children. |
“There’s no clinical data to support boosters in children” | Dr. Sean O’Leary: Booster guidance is based on immune waning and clinical outcomes. Multiple studies have shown safety and immune response benefits in children. |
"In pregnancy COVID vaccines cause increased fetal loss, pre-term births and placental blood clots" | Dr. Steven Fleischman (ACOG): “The science has not changed.” COVID infection during pregnancy is dangerous. The vaccine is safe and protective for mother and infant. |
Basis for removing vaccine from schedule: “No evidence it’s needed in healthy kids or pregnant women” | Experts disagree: ACOG, CDC, and ACIP all emphasize the ongoing risks of COVID for pregnant individuals and newborns. Infants under 6 months are most vulnerable, and studies show that vaccination in pregnancy protects them after birth. |
Now that we've addressed those issues, let's talk more about COVID mRNA vaccine safety and what's actually in the vials. I go over this in my episode on pregnancy and vaccines but we need it here too. OK, so ACOG says you should get the currently recommended COVID-19 vaccine if you are pregnant and not up to date on your COVID-19 vaccines.
Multiple studies, including systematic reviews and large cohort studies, have shown that COVID-19 vaccination during pregnancy is safe and effective. They protect moms-to-be and infants from COVID disease. mRNA vaccines, such as Pfizer-BioNTech and Moderna, including the updated formulations targeting Omicron variants, were always recommended by the CDC and WHO before RFK let loose his antivax agenda. The truth is, COVID-19 vaccination in pregnant women reduces the risk of severe COVID-19 and also decreases the chance of preterm birth associated with maternal infection. ACOG says, "If you are pregnant or postpartum, you have a higher risk for more severe illness from COVID-19 than people who are not pregnant. Stay up to date on COVID-19 vaccines."
OK, so the fear mongering and disinformation campaigns against these vaccines get people killed. The antivax movement is a concerted effort by people with a financial stake in the movement. Please listen to, or read, my episode on Andrew Wakefield to understand how it all started and why it's all bullshit. If there were people dying from these vaccines we would have evidence of that. There is none. The evidence is that these vaccines save lives. You know what kills people and causes long-term illness that we are still figuring out the extent of? COVID-19. mRNA vaccine technology was a revolutionary achievement that saved millions of lives. We still had over 300 people dying from COVID each week in April 2025. Call your reps and demand that they fight to keep vaccines, including COVID-19 vaccines, accessible to all Americans. We all need them, but pregnant women and children are especially vulnerable to severe disease.
So let's get into what is actually in the mRNA vaccines.
Pfizer-BioNTech: COMIRNATY (COVID-19 Vaccine, mRNA) is a sterile suspension for intramuscular injection. Here's the package insert:
Each dose contains:
Antigen - the part of the pathogen that elicits an immune response. This one uses messenger RNA (modRNA) encoding the viral spike (S) glycoprotein of SARS-CoV-2 Omicron variant lineage KP.2. This means our bodies will make the protein using the mRNA as a blueprint. The mRNA then degrades as all mRNA does. Our bodies have mRNA naturally, they are the blueprints for protein production. This technology is safe and effective but for the nitty-gritty details check out my mRNA vaccine episode.
Delivery components: these are used to formulate the lipid nanoparticles (LNPs) that protect the fragile mRNA and help deliver it into cells:
Lipids
2-(Polyethylene glycol 2000)-N,N-ditetradecylacetamide: A PEG-lipid conjugate used to stabilize the LNP structure and increase circulation time.
1,2-distearoyl-sn-glycero-3-phosphocholine (DSPC): A phospholipid that helps form the lipid bilayer of the nanoparticle.
Cholesterol: Contributes to the fluidity and stability of the lipid nanoparticle membrane.
Stabilizers:
Tromethamine (Tris) and Tromethamine Hydrochloride (Tris HCl)
Buffers that maintain the pH of the vaccine formulation.
Sucrose
Acts as a cryoprotectant to stabilize the lipid nanoparticles during freezing and thawing.
Preservatives: COMIRNATY does not contain preservatives.
Moderna: SPIKEVAX (COVID-19 Vaccine, mRNA) is a sterile suspension for intramuscular injection. Here's the package insert:
Each dose (2024-2025 Formula) contains:
Antigen: messenger RNA (mRNA) encoding the pre-fusion stabilized Spike glycoprotein (S) of the SARS-CoV-2 Omicron variant lineage KP.2.
Delivery components: these are used to formulate the lipid nanoparticles (LNPs) that protect the fragile mRNA and help deliver it into cells:
Lipids:
SM-102: A proprietary ionizable lipid that binds to the negatively charged mRNA, forming stable LNPs and facilitating cellular uptake.
Cholesterol: Provides membrane stability and flexibility to the lipid nanoparticles.
1,2-distearoyl-sn-glycero-3-phosphocholine (DSPC): A phospholipid that helps form the structural bilayer of the LNP.
PEG2000-DMG (polyethylene glycol 2000-dimyristoyl glycerol): A PEG-lipid that stabilizes the LNPs and extends their circulation time in the body.
Stabilizers
Tromethamine (Tris): A buffer to maintain an optimal pH.
Tromethamine hydrochloride (Tris HCl): Provides additional pH stabilization.
Acetic acid and Sodium acetate: These work together as a buffer system to help control pH.
Sucrose: Acts as a cryoprotectant, preventing damage during freezing and thawing.
Preservatives: SPIKEVAX does not contain a preservative.
So that's what in the mRNA vaccines, let's talk about how they actually work. I have an entire episode on COVID mRNA vaccines but because RFKjr and his antivax buddies keep saying so much bullshit about this, I will go over it again here for you.
How mRNA Vaccines Work: A Story of Molecular Precision
Let’s strip it down to the basics—because understanding how COVID-19 vaccines work doesn’t require a biology degree. It just takes a little storytelling. Inside every living thing, including us, is a cellular system for building proteins. Think of it like a highly specialized factory. And the instructions for those proteins? They come in the form of messenger RNA—or mRNA. These little strands are like post-it notes for your cells: quick, disposable messages that tell the machinery what to make.
Now enter the mRNA vaccine.
Instead of using a weakened or killed version of the virus—like traditional vaccines do—the COVID-19 mRNA vaccines simply deliver one message: “Build this spike protein.” That spike is the distinctive part of the virus—the same one it uses to invade our cells. Once the mRNA is delivered, wrapped in a tiny lipid (fat) bubble to help it reach the inside of our cells, the message is read, the spike protein is built, and then… the message self-destructs. It’s temporary. It never enters the cell’s nucleus. It can’t alter your DNA. It doesn’t stick around. It’s just the molecular equivalent of writing something down, passing it along, and shredding it when you’re done.
What happens next is where the magic really begins.
Your immune system sees the spike protein—now floating inside you—and says, “Hey, that’s not supposed to be here.” It builds antibodies. It creates memory. It gets ready for battle. So when the real virus shows up later, your body already has a playbook. It knows how to stop the threat before it causes serious damage.
What makes this approach so revolutionary isn’t just the speed at which it can be developed—it’s the precision. And the safety. Because mRNA is something your body uses all the time. These vaccines just give it a head start.
And what about side effects? Yes, people report soreness, fever, fatigue. But those are signs the vaccine is working—evidence of your immune system doing its job. In fact, out of nearly 1.9 million early Pfizer doses, only about 0.2% reported any unpleasant reaction.
It’s also important to know: while the approval process for these vaccines moved faster than ever before, that speed didn’t mean skipping safety steps. Every phase—animal studies, small-scale human trials, large-scale efficacy testing—was completed, reviewed, and monitored. The urgency wasn’t in cutting corners—it was in saving lives. The corner-cutting was with bureaucratic steps not science or safety assessments.
The effectiveness? In the early months, it was remarkable: around 90–95% for preventing symptomatic infection. And while we still don’t know exactly how long immunity lasts, evidence shows that for many, vaccines provide better and longer protection than infection alone.
The bottom line? mRNA vaccines don’t change who you are. They don’t linger. They don’t hack your DNA. They just teach your immune system a single lesson: how to recognize and fight one very specific intruder.
But you need boosters. No only because protection isn't long term but because the virus mutates quickly. We can't allow the antivax goons take away our access to lifesaving vaccines. Please call your representatives. Letters aren't as effective. You need to call. Repeatedly and you need to vote out anyone who makes us less safe.
OK, so we got vaccinated or we didn't, and we got COVID and are sick. Let's talk about treatment options.
Anti-COVID Antibodies and Antivirals: What Works, What Doesn’t
Monoclonal Antibodies: What We Learned, and What Comes Next: For immunocompromised people — including lung transplant recipients — monoclonal antibodies (or mAbs) were once a crucial tool in preventing and treating COVID-19. These lab-made proteins mimic the body’s immune response and were shown to reduce hospitalizations and deaths when given early in the course of infection. They were also used for pre-exposure prevention in high-risk patients who didn’t mount strong vaccine responses.
But here’s the catch: most of the mAbs used earlier in the pandemic — like sotrovimab, tixagevimab/cilgavimab, and casirivimab — have since lost effectiveness as new SARS-CoV-2 variants emerged. While they were generally safe and well tolerated, evolving variants rendered many of them obsolete.
Still, the experience highlighted the potential of mAbs for rapidly deploying targeted treatments during outbreaks. And in March 2024, a new antibody — pemivibart — received emergency authorization as pre-exposure prophylaxis for severely immunocompromised people. Its effectiveness in transplant recipients like lung patients remains under study.
The key takeaway? Monoclonal antibodies showed promise in protecting the most vulnerable, but keeping pace with a fast-mutating virus remains a major challenge. Going forward, these therapies may play a broader role — not just in COVID, but in other infections where vaccines or antivirals fall short.
Now onto antivirals: In the era of Omicron and widespread immunity, the role of COVID-19 antivirals has shifted. For most people today — especially those vaccinated — treatment is less about preventing hospitalization and more about shortening symptoms, reducing how long they’re contagious, and potentially preventing long COVID.
The evidence is mixed. A nice review from last year gave me these insights:
🔹 Remdesivir, the first approved antiviral, still works — but requires three days of IV treatment, making it impractical for most outpatients.
🔹 Molnupiravir offers modest benefits, especially in unvaccinated, high-risk adults — but newer studies in vaccinated populations show little effect on hospitalization or death. There are concerns about potential mutagenic risks and it’s not recommended during pregnancy.
🔹 Paxlovid (nirmatrelvir-ritonavir) remains the strongest option for high-risk adults. It cuts hospitalization risk significantly—but comes with common drug interactions and side effects. A major downside? Viral rebound. Many people see symptoms and viral load return after completing treatment, especially with Omicron. That may also mean extended infectiousness.
🔹New antivirals like Ensitrelvir and VV116 show early promise — with some data suggesting faster recovery and even reduced risk of long COVID—but they’re not widely available outside Asia.
🔹There’s also growing interest in metformin, which in one large trial reduced the chance of developing long COVID when given early in unvaccinated people.
Now, all of the treatments in the review were evaluated for acute COVID-19, not long COVID.
However, there are a few important caveats:
Primary endpoints in these trials typically focused on short-term outcomes: symptom duration, hospitalization, death, or viral load. Long COVID (more on that in a minute) was not the main focus of any of these studies.
That said, a few trials—like the one on metformin and exploratory analyses of ensitrelvir—did look at long COVID as a secondary or follow-up outcome, with some promising signals of benefit (e.g., reduced incidence of persistent symptoms). So while none of these drugs are currently approved or proven to treat long COVID itself, early treatment of acute COVID may influence long-term outcomes, and that’s an area of active investigation.
Still, major gaps remain in treatments. Many trials excluded pregnant people, children, and the immunocompromised, leaving doctors guessing in some of the highest-risk cases. And for standard-risk, vaccinated patients, the benefit of antivirals is increasingly about faster recovery—not necessarily fewer hospitalizations.
As the virus evolves and rebounds become more common, we need updated tools — not just better drugs, but smarter trial designs that reflect today’s COVID reality. And before we move on to a different topic, I want to show you guys want inequity in healthcare looks like with a glaring example from 2020.
Presidential Privilege in COVID Care
During his first term, the orange one was hospitalized with COVID-19 in 2020, and he received an aggressive combination of treatments — remdesivir, dexamethasone, and an experimental monoclonal antibody therapy from Regeneron. The latter wasn’t FDA-approved as a COVID treatment until four years later and had only been tested in a small number of people at the time. Most Americans wouldn't have been able to access all three drugs, let alone in such rapid succession.
In many ways, Trump’s treatment reflects what’s possible when cost, access, and speed are no obstacle. But it also highlights the deep gaps in our healthcare system — ones that have only widened since, especially as policy shifts threaten Medicaid, Medicare protections, and drug access under HHS leadership.
As we think about coming elections, it's worth remembering that how we treat all infectious diseases—and who gets access to vaccines, treatments, and all healthcare resources—is still deeply shaped by politics, privilege, and policy. If you care about it, make your voice heard.
OK, So Where Are We on Mitigation?
We know the US is useless right now in this regard but what about the rest of the world? Well, since the formal end of the global health emergency in May 2023, the world’s pandemic playbook has fractured. National responses vary dramatically. Some countries have folded COVID-19 into broader respiratory programs, integrating it alongside influenza and RSV, which is where you cna find it on the CDC website... for now, anyway. Others are still in flux, managing COVID through temporary, vertical structures while trying to reshape their surveillance and care systems for long-term sustainability.
And before we get into the WHO's strategy we need a brief sidebar on something called One health.
Sidebar on One Health: One Health is a term you’ve probably heard, but maybe haven’t unpacked. And it turns out it’s more than a slogan. It’s a unifying approach that recognizes a simple but powerful truth: human health is deeply interconnected with the health of animals, plants, and the environments we share.
Diseases don’t respect boundaries—not between species, not between countries. Think of zoonotic viruses, antibiotic resistance, or disruptions to the food chain. One Health brings medical, veterinary, environmental, and public health experts to the same table—because controlling disease means looking across systems, not just within them.
By linking people, animals, and ecosystems, One Health helps us build stronger defenses. From prevention to detection, from response to long-term resilience, it’s about seeing the whole landscape—so that the next outbreak doesn’t catch us flat-footed.
And the work doesn’t only happen at the global level. One Health lives in community clinics, local farms, water systems, wildlife tracking stations—anywhere that early warning signs might surface. With better coordination and shared governance, we gain clearer vision across sectors and clearer pathways to collective protection.
In a post-pandemic world, One Health isn’t just a framework—it’s a necessity.
Now that we know what One Health is, I can explain that, at the heart of the WHO’s new guidance on COVID is a One Health model—a strategy that sees COVID-19 not as a siloed crisis, but as part of the wider respiratory disease threat landscape.
The WHO’s One Health Initiative
Through its One Health Initiative, WHO plays a central role in bringing this approach to life. It acts as the Secretariat for several major coordination efforts:
The High-Level Expert Panel on One Health,
The internal WHO Coordination (WIC) group on One Health,
And the Quadripartite Collaboration between WHO, FAO, UNEP, and the World Organisation for Animal Health (WOAH).
Together, this network helps set a global research agenda, develop integrated policy frameworks, and support countries as they adapt One Health principles to their own landscapes—rural or urban, high-income or low-resource.
So what does that actually look like?
The WHO’s initiative focuses on three core objectives (From their website):
Revitalize the One Health approach to reduce vulnerability of people from health emergencies and enjoying better health and well-being;
Expand the One Health approach to include the environmental component (e.g., change in land use and increasingly urbanized ecosystems) to the human-animal interface approach, and consider the links between human, animal and ecosystem health; and
Operationalize the One Health approach through a set of activities to reduce the risk and mitigate the impact of future emergence of zoonotic and vector-borne diseases, endemic and emerging, infectious and non-communicable diseases, with a focus on emerging zoonoses that have epidemic or pandemic potential.
In other words, this isn’t just about catching outbreaks. It’s about preventing them—by understanding how human behavior, environmental stress, and animal health intersect, and by investing in systems that can respond before the next virus leaps from forest to farm to family.
The idea is to build layered systems where surveillance, genomics, vaccine delivery, clinical pathways, and public engagement work together, continuously. Many countries are already moving toward that model, building out platforms like GISRS (the Global Influenza Surveillance and Response System) and CoViNet, which combine sentinel site testing, variant tracking, and wastewater monitoring under one roof. The US currently participates in these but to what extent are we actually providing data? I have no idea.
Meanwhile, clinical systems are also adapting. Hospitals that once created crisis workflows for COVID are now embedding them in routine care models—not just for acute illness, but for long COVID as well. Vaccines are being offered alongside seasonal flu and RSV shots, particularly for older adults and high-risk groups. And public health campaigns continue, though often with smaller budgets and less urgency.
But beneath all of this progress is a quiet, global tension: funding. The infrastructure may be maturing, but the financial support sustaining it is not. From high-income countries to the most resource-constrained, health systems are straining under the weight of competing priorities: recovering disrupted services, managing rising non-communicable disease burdens, staffing shortages, and preparing for the next threat—whatever it might be.
And beyond the health sector? The obstacles are just as pressing: inflation, political instability, and humanitarian crises make it harder to maintain even the most basic COVID-19 programs in many parts of the world. And as we see in the US, disinformation and politics are leading to people losing access to vaccines but also healthcare and public health infrastructure. We're in real trouble.
The WHO continues to coordinate global guidance, offer technical support, and encourage countries to embed pandemic lessons into long-term respiratory care frameworks. But what it can’t do is ensure that political will and sustainable investment follow. And that, more than any one variant or surge, may be the most enduring threat we face.
What’s the Risk Now?
Despite the recent rise in activity, WHO assesses the global public health risk as high—but not catastrophic. Why? Because most people now have some immunity, and currently circulating variants, including NB.1.8.1, don’t appear significantly more dangerous than past ones. But unpredictability remains the watchword. There’s no clear seasonality, and evolution continues. The recommendation? Maintain surveillance, vaccinate the vulnerable, and don’t let your guard down. But that means people need access to vaccines. Yeah, fingers crossed on that one. We might be looking at vaccine tourism here soon.
And I wish i was kidding, but I'm not. Preventing COVID is more important than ever as we learn more and more about long COVID and cumulative sequalae.
What We Now Know About Long COVID
Millions of people are still feeling COVID effects five years after it exploded across the planet—not because they’re constantly reinfected, but because they never fully recovered. Long COVID, once a fringe concern, is now recognized as a real and persistent condition. And yet, despite its widespread impact, it’s still often misunderstood.
A recent review in The Lancet offers one of the clearest summaries yet of what long COVID is, how it works, and where the science is heading.
What Is Long COVID?
The term “long COVID” was coined by patients in mid-2020, trying to put a name to the baffling symptoms that lingered long after their initial infection. Since then, public health bodies have adopted various definitions. The World Health Organization defines it as symptoms lasting more than three months post-infection. In the U.S., it's any symptoms continuing beyond four weeks. In the UK, long COVID includes both “ongoing symptomatic COVID-19” (4–12 weeks) and “post-COVID-19 syndrome” (12+ weeks).
The lack of a unified definition reflects a deeper issue: we still don’t fully understand how the virus triggers long-term illness. There’s no test, no single biomarker, and no one-size-fits-all treatment.
So, How Common Is It?
Prevalence estimates vary, depending on the population studied and the timing of measurement. Among unvaccinated patients who were hospitalized, up to 85% report ongoing symptoms. For non-hospitalized but unvaccinated individuals, the rate ranges from 10% to 35%. Even in vaccinated people, roughly 8–12% still report persistent symptoms.
In early 2024, the UK’s Office of National Statistics found an estimated 3.3% of people (around 2 million) in private households reported symptoms lasting more than four weeks after COVID infection—up slightly from 2.9% in March 2023.
Of those, 74.7% said their symptoms interfered with daily life, and 19.2% reported being "limited a lot."
Most long COVID sufferers had been symptomatic for a long time:
71% for over a year
51.3% for at least two years
30.6% for over three years
A Condition With Many Faces
Long COVID isn't a single disease but a multisystem syndrome that can involve over 200 symptoms. Common complaints include:
Exhaustion that worsens with exertion
Cognitive difficulties (“brain fog”)
Shortness of breath and chest tightness
Dizziness, joint pain, digestive issues
Mood disorders such as anxiety and depression
Many people report an overwhelming loss of energy—so-called “energy poverty”—that makes it hard to work, care for family, or even carry out basic tasks. One UK survey found that 5.7% of those not working cited long COVID as the reason.
What’s Going On in the Body?
The exact mechanisms are still under investigation, but researchers have identified three major contributors:
Viral persistence – pieces of the virus may linger in tissues, continuing to provoke inflammation.
Immune dysfunction – including abnormal immune responses and autoimmune activity.
Vascular issues – microclots and inflammation in blood vessels may impair oxygen delivery and organ function.
Other possible factors include disrupted gut microbiomes, hormonal imbalances, mitochondrial dysfunction, and even changes in brainstem signaling. Long COVID appears to be less about one single cause and more about a cascade of interrelated systems gone awry.
Treatment and Support
There’s no universal cure for long COVID, but that doesn’t mean there’s no help. The most effective care starts with listening. A careful history, symptom tracking, and continuity with a trusted clinician are key.
Management often includes:
Symptom-guided pacing (as opposed to pushing through fatigue)
Breathing therapy and physical rehab
Speech, cognitive, and psychological support
Diet, sleep, and lifestyle adjustments
Multidisciplinary teams tend to offer the best outcomes, but access to such care remains uneven across regions and income levels.
Can It Be Prevented? Yes—largely. The best way to avoid long COVID is to prevent infection in the first place. Vaccination significantly reduces the risk. Three doses cut the chance of developing long COVID by nearly 69%. Antiviral treatments like Paxlovid, taken early, also appear to help. But, and please hear me! Clean air, high-quality masks, and avoiding crowded indoor spaces are your most effective tools.
So, let's talk more about masks.
Sidebar on Masks: A Preventive Tool in the Ongoing Pandemic
At the height of the pandemic, mask-wearing became a lightning rod for political and cultural conflict. But beneath the noise, a large body of evidence has steadily grown — and it tells a clear story: masks work, especially when used widely and correctly.
While the earliest public messaging in some countries discouraged mask use (partly due to supply concerns for healthcare workers), the scientific consensus has since solidified. Masks help reduce transmission of SARS-CoV-2, particularly in indoor and poorly ventilated spaces where airborne particles accumulate.
But not all masks are created equal.
N95 respirators — which are certified to block at least 95% of very small airborne particles — offer the highest level of protection, especially for the person wearing the mask. Their tight fit and multilayer filtration make them superior to both cloth and surgical masks in preventing inhalation of viral particles. That’s why they remain the gold standard for healthcare workers and others at high risk.
In controlled experiments, even slight improvements in mask fit — like using clips or braces — significantly increased their effectiveness. However, some modified surgical and cloth masks came close to the performance of N95s, especially for source control (protecting others). But when it comes to protecting the wearer, especially in high-risk environments or during surges, a properly fitted N95 remains the most effective option.
That said, even basic cloth masks played a crucial role during periods of widespread transmission. Worn consistently and correctly, they helped reduce the emission of infectious aerosols, functioning as an important public health measure—especially when worn universally.
The takeaway? In a pandemic driven by airborne transmission, clean air and high-quality masks are powerful tools. Even if mandates are gone, masks remain a smart choice — particularly in crowded indoor spaces, healthcare settings, or when viral spread is high.
And I can't say this loud enough: People who are infectious need to wear masks! Protecting others from your infectious disease is paramount in keeping people safe. Me wearing my mask is way more effective if you, the sick person is also wearing a mask. Don't be a dick. If you're sick, wear a mask. Or better yet stay home. And if you're super nice, you'll wear a mask at home to protect the people you love most.
OK, back to the episode. We were talking about long covid.
The Role of Reinfection
OK, so another unsettling reality is that long COVID risk appears to increase with each subsequent infection. It’s not just a one-time hazard.
In a study of nearly 140,000 U.S. veterans, researchers found that a second infection raised the risk of long COVID—and a third infection raised it further. The damage adds up. Canadian studies and analyses of over a million U.S. patients have shown similar patterns: more infections, more risk.
Dr. Rambod Rouhbakhsh, speaking on an American Medical Association podcast in 2023, summed it up clearly: “Each subsequent COVID infection increases your risk of developing chronic health issues... It is akin to playing Russian roulette.”
Why Does This Happen?
SARS-CoV-2 attacks memory T cells—key components of our long-term immunity. It forces them into self-destruction, weakening the body’s defenses not only against COVID, but also other infections like RSV or pneumonia. Each infection may chip away at the immune system, even if symptoms are mild.
The Road Ahead
So where do we go from here? There are over 400 clinical trials currently underway to find effective long COVID treatments. Researchers are beginning to identify different “types” of long COVID based on biomarkers, which could open the door to personalized therapies.
Patients, who first named the condition and pushed for recognition, remain central to progress. They continue to lead advocacy efforts, and many signed an open letter urging more federal support, better clinic access, and long-term disability protections. But we're not in a position to expect the antivax admin to act on it. Still we must advocate for it. We can't give up.
And as the virus continues to evolve, new variants and waning immunity will present new challenges to our public health infrastructures and healthcare resources. If we don't make sure our vaccines keep up with the viruses, we will be in trouble. Long COVID is not just a lingering flu. It’s a large-scale, long-term public health crisis—one with the potential to reshape our workforce, our healthcare system, and how we think about viral illness. With US defenses disabled, it will become a national health problem unlike anything we've seen. I can only hope other countries will stay in front of this virus.
Final Thoughts
It's important to understand that the story of COVID isn’t over. It’s just moved into a different chapter—one with quieter pages but important subplots: under-vaccination, evolving variants, systemic fatigue, and long-COVID picking up. We have the tools we need but do we have the will to use them? As we move into the second half of 2025, public health leaders worldwide are calling not for panic, but for perseverance. Vigilance. And yes, vaccination.
We may be done with the pandemic but the pandemic is not done with us.
Follow me on BlueSky (and Twitter if you can stomach it).
Stay healthy, stay informed, and spread knowledge not disease.
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