DENVER Flu and RSV have come and gone this year, so if cold-like symptoms have been putting a damper on your summer plans these past few weeks, Colorado health experts say its very likely the coronavirus is to blame.
The state just like pretty much the rest of the country is experiencing a rise in COVID-19 cases this summer due to two different strains from the Omicron family KP.2 and KP.3. Nicknamed FLiRT by variant trackers to help the public better understand the wide variety of circulating strains of the virus, these two strains combined which may be better able at getting past the bodys defenses due to mutations in the spike protein accounted for nearly 55% of all strains circulating across the state as of June, the most recent data the state has.
Since about April of this year, we've started noticing an increasing trend in the number of COVID cases that have been going on in the state of Colorado, said Dr. Ming Wu, a primary care physician at AdventHealth in Littleton. We've seen more cases in the clinics, people testing positive for COVID.
U.S. Centers for Disease Control and Prevention (CDC)
Data from the state confirms those observations. COVID-19 cases have been on an upward trend since mid-May in Colorado, with nearly 1,300 new cases reported in just the last week alone, according to the latest data from the Colorado Department of Public Health and Environment (CDPHE). Those numbers are likely an undercount, however, since most people now test at home if at all and the majority dont report their results to state or federal health authorities.
Hospitalizations for COVID-19 in Colorado have also increased to levels not seen since March, with 111 people hospitalized for the disease as of Tuesday compared to 66 at this same time last year a nearly 70% increase when comparing year-to-year.
Across the country, emergency room visits for COVID-19 increased to 23.5% as of July 6, according to the U.S. Centers for Disease Control and Prevention (CDC), with about 1.3 hospitalizations per 100,000 people. Though the numbers might seem concerning, they are still lower than last winter, when 7.7 hospitalizations per 100,000 people were reported by the CDC. It's not clear, however, how accurate this picture really is since hospitals are no longer required to report COVID-19 hospital admissions to the federal government.
Concentrations of the virus in wastewater which has replaced case numbers as a more reliable metric to show how prevalent the virus might be in the community have also increased over the past several weeks across the state, with more than half of all treatment facilities showing steady increases in viral replication since early May, when none were, according to CDPHE data.
The fact that we still have thousands 2,000 cases every week that are (being) reported is of concern, said Dr. May Chu, a clinical professor at the Colorado School of Public Health. It should tell us that we shouldn't forget that SARS-CoV-2 is still amongst us. It has not gone away.
Though it may be surprising to some to see a rise in COVID-19 cases over the summer, Chu said that ever since SARS-CoV-2 appeared on the map, Colorado along with the rest of the country has always had a summer surge.
U.S. Centers for Disease Control and Prevention (CDC)
Chu said that virologists like herself expect that as the virus continues to circulate in people for the foreseeable future, that a regular pacing might occur and then we can begin to predict when it could occur, probably along with the other respiratory viruses.
Its not clear if that will ever come to pass, however, as the CDC quietly admitted in an update posted over the Fourth of July holiday that SARS-CoV-2 is likely to remain a year-round threat given there is no distinct COVID-19 season like there is for influenza (flu) and respiratory syncytial virus (RSV)."
In its update, the CDC recommended a multi-layered approach so you can protect yourself against infection and prevent others from becoming infected with SARS-CoV-2. The multi-layered approach includes getting vaccinated, wearing a well-fitting, high-quality mask, ventilating indoor spaces, practicing proper hand hygiene, and following CDC quarantine guidance if you test positive for the virus.
CDC officials say a number of factors could be at play, including new variants that are not just more transmissible but better able at getting past our bodys defenses, as well as decreasing immunity from previous infections and vaccinations.
Though the newer FLiRT variants have mutations that make them more transmissible, Chu said those mutations arent statistically important as their rate of transmission only varies slightly compared to previous strains. However, because many different strains of the virus are circulating at the same time, you can imagine that theres a lot more virus growing, she said.
Part of it, too, is a bit of the virus variation. The virus still is young enough that it'll keep changing based on environmental circumstances, Chu said, adding that as it changes, it could get worse or it could get less infectious. We actually dont know.
Wu, on the other hand, attributed the rise in COVID-19 infections to the low uptake of vaccines across the state.
Data from the CDPHE shows about 30% of Coloradans ages 5 and up have only gotten 3 doses of the COVID-19 vaccine (up to 6 doses are available now for certain groups of people).
A lot of patients have said, you know, I've gotten enough COVID vaccines. I don't want this one, and so they haven't gotten it, Wu said.
While COVID-19 vaccines can protect you from getting seriously ill, they might not protect you against SARS-CoV-2 infection, both experts said.
If youre in a room that's tightly closed, with a lot of people that you don't know, you should mask because that increases the chance the transmission, Chu said. If you are the vessel for the reproduction of that virus, you're going to make yourself sick, and other people are likely to get it from you. So you just have to be careful.
Wu agreed, adding other measures like handwashing and socially distancing from others if you're sick could help protect not just yourself but others as well.
COVID cases are on the rise across the US
If you do feel ill and you need to go out, wear a mask to protect your neighbor. If you sneeze and your germs aren't spreading everywhere, you're preventing your neighbor from getting that virus and so you're protecting the community, he said.
If you test positive for COVID-19, Chu recommends calling your healthcare provider immediately and seek antiviral treatment like Paxlovid as soon as you can as itll help you from getting worse.
Those looking for added protection should get vaccinated now against COVID-19, both experts said, though if you want to wait it out a little longer, an updated COVID-19 vaccine targeting the most recent variants will be available later this year.
Though scientists and other health experts have seen a trend toward less severe outcomes and more typical symptoms of the flu with each new wave of the coronavirus, an encounter with COVID-19 doesnt come without risks.
With flu, there is not the residual Long COVID symptoms that about 8% of people suffer from. Flu doesnt have that. RSV doesnt have as much of that, Chu said. It is a risk and because this virus is still adapting to people, you're going to have lots of cases.
While people who have had severe COVID-19 are at increased risk of developing Long COVID, CDC officials have said Long COVID can affect anyone, including children. Commonly reported symptoms include fatigue, brain fog and post-exertional malaise (PEM), but more than 200 symptoms have been associated with the condition which can affect various organs of the body, including the brain, the heart, the lungs, the kidneys, the reproductive system, among others.
The illness can last for weeks, months, or even years, and can be debilitating in ways that significantly limit the daily activities of affected individuals, according to the latest annual report on Long COVID in Colorado. Its believed Long COVID has affected 10% of the states population so far.
Chu said that while scientists have been able to learn more about Long COVID since the start of the coronavirus pandemic four years ago, the outcome at the moment still doesnt tell you exactly how we can predict one, if you can get Long COVID, and two what your symptoms are (going to be). We're still gathering that information.
Which is why Chu said its important for Coloradans to remember that COVID-19 is still around us and to be aware of the risk each infection can bring.
If you are able to mitigate it, or reduce it by masking, by the various different kinds of practices that we've all known about for (years) now that continue to be in effect, then the risk of (developing Long COVID) gets lower, she said.
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ILLUSTRATION - 14 September 2023, Berlin: An antigen test to detect Covid-19 for self-testing. For a long time, Corona was no longer a big issue. Now the curve is rising again. Photo: Jens Kalaene/dpa (Photo by Jens Kalaene/picture alliance via Getty Images)
(NewsNation) An overlooked symptom of COVID-19 can cause long-term issues in many patients, according to a study by the British Medical Journal.
Common symptoms of COVID-19 include a sore throat, congestion, fatigue, muscle aches and fevers. Earlier in the pandemic, it was also common to lose ones sense of smell or taste.
According to the British Medical Journal, COVID-19 can also cause stomach and gastrointestinal issues such as lack of appetite, nausea and vomiting, diarrhea and abdominal pain. The journal states that around 50% of people experience some of these symptoms after an infection.
The COVID-19 virus particles that cause lung illness also infect the gastrointestinal tract, which consists of the esophagus, stomach, small intestines and colon. Dr. Christopher Vlez said in an article published by Harvard Medical School that these virus particles can trigger abdominal pain and diarrhea for those with COVID-19.
Many researchers have observed that the virus can cause long-lasting symptoms, referred to as long COVID. Reported effects of this often include tiredness, breathing difficulty, heart rhythm changes and muscle pain.
Some medical professionals believe that chronic gut symptoms could be occurring as a form of long-term COVID-19. Vlez wrote that one possible insight is post-infectious irritable bowel syndrome, which is when the network of nerves that connects the gut and the brain is disrupted by something such as the stomach flu.
These nerves could be disrupted by COVID-19 long after the virus causing the illness is gone.
Even if the process of digestion remains normal, you may frequently have symptoms like pain or a distressing change in your bowel movements, such as diarrhea or constipation, Vlez said in the article.
A study from the University of Oklahoma College of Medicine found a connection between COVID-19 and gastrointestinal symptoms. Dr. William Tierney, who led the study, said there is clear evidence linking the two.
COVID could be the trigger for a patients long-term digestive symptoms, Tierney said.
Media Advisory
Thursday, July 11, 2024
NIH-funded analysis of health record data shows severe reinfections often follow severe first infections.
Using health data from almost 213,000 Americans who experienced reinfections, researchers have found that severe infections from the virus that causes COVID-19 tend to foreshadow similar severity of infection the next time a person contracts the disease. Additionally, scientists discovered that long COVID was more likely to occur after a first infection compared to a reinfection. The study, funded by the National Institutes of Healths (NIH) Researching COVID to Enhance Recovery (RECOVER) Initiative, is published in Communications Medicine.
The analysis used data from electronic health records of 3.1 million Americans who are part of the National COVID Cohort Collaborative (N3C). Researchers focused on 212,984 people who reported a reinfection. Those individuals were originally infected between March 1, 2020-Dec. 31, 2022, and experienced a second infection by March 2023. Most participants (203,735) had COVID-19 twice, but a small number (478) had it three times or more. COVID-19 vaccines, though not available during the entire study period, correlated with a protective effect.
About 27% of those with severe cases, defined as receiving hospital care for a coronavirus infection, also received hospital care for a reinfection. Adults with severe cases were more likely to have underlying health conditions and be ages 60 or older. In contrast, about 87% of those who had mild COVID cases that did not require hospital care the first time also had mild cases of reinfections.
Reinfections were defined as having occurred at least two months after a first infection. They were found to occur most frequently when omicron variants were circulating in late 2021 and early 2022. Waning immunity and increased exposure to the coronavirus, including the highly-infectious variants, likely accounted for the uptick.
Scientists also discovered that regardless of the variant, long COVID cases were more likely to occur after a first infection compared to a reinfection. Long COVID was defined in the review as those experiencing long-term COVID-19 symptoms, such as feeling tired, coughing, or having problems sleeping, breathing, or thinking, after an acute coronavirus infection.
Researchers also found that lower levels of albumin, a protein made by the liver, may indicate a higher risk for reinfection. This finding could indicate lower albumin as a possible risk marker for reinfection. Scientists believe this deserves further attention, such as by considering trials to test if nutritional interventions may prevent reinfection or its severity.
The study is funded by NIHs RECOVER Initiative. Additional support came from the N3C Data Enclave, which is supported by the National Center for Advancing Translational Sciences, also part of NIH.
David C. Goff, M.D., Ph.D., a senior scientific program director for the RECOVER Observational Consortium Steering Committee and director of the Division of Cardiovascular Sciences at the National Heart, Lung, and Blood Institute (NHLBI), part of NIH, is available for interviews on this paper.
Hadley E, Yoo YJ, Patel S, et al. Insights from an N3C RECOVER EHR-based cohort study characterizing SARS-CoV-2 reinfections and Long COVID. Commun Med. 2024; doi: 10.1038/s43856-024-00539-2.
HHS Long COVID Coordination: This work is a part of the National Research Action Plan (PDF, 1.3 MB), a broader government-wide effort in response to the Presidential Memorandum directing the Secretary for the Department of Health and Human Services to mount a full and effective response to long COVID. Led by Assistant Secretary for Health Admiral Rachel Levine, the Plan and its companion Services and Supports for Longer-term Impacts of COVID-19 report (PDF, 1.6 MB) lay the groundwork to advance progress in the prevention, diagnosis, treatment, and provision of services for individuals experiencing long COVID.
About RECOVER: The National Institutes of Health Researching COVID to Enhance Recovery (NIH RECOVER) Initiative brings together clinicians, scientists, caregivers, patients, and community members to understand, diagnose, and treat long COVID. RECOVER has created one of the largest and most diverse groups of long COVID study participants in the world. In addition, RECOVER clinical trials are testing potential interventions across five symptom focus areas. For more information, please visit recoverCOVID.org.
About the National Institutes of Health (NIH): NIH, the nation's medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information about NIH and its programs, visit www.nih.gov.
NIHTurning Discovery Into Health
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COVID transmission has climbed steadily since the spring, according to data from hospital patients COVID tests. New York states wastewater concentrations have held steady so far, but city wastewater data shows that some parts of the city are in the 80th percentile or above compared to past COVID levels.
New York Citys hospitalization rate is elevated compared to last summers figures, but it hasnt quite caught up to the most recent December-January peak. NYC Health and Hospitals, the citys public hospital system, reinstated its mask mandate as of last December, the New York Daily News reported. And in July, the city health department re-upped its recommendation that New Yorkers wear masks indoors.
In recent weeks, the viral landscape has been dominated by the FLiRT variants, a collective name for a family of substrains whose technical names start with JN and KP. The capital letters in FLiRT are shorthand for the mutations that help these substrains cling to our cells and fend off antibodies, according to the Bloomberg School of Public Health at Johns Hopkins University.
Theres not much available research yet on the most recent COVID vaccines effectiveness against the new variants. But the shots can still protect against severe disease, hospitalization and death, according to the CDC.
A new study led by researchers from the Wayne State University of School of Medicine has revealed a trending seasonality to yearly COVID-19 surges, specifically two smaller peaks in the spring and summer, and the largest peak in the winter.
Our study also revealed that climatic factors, such as temperature and rainfall, do not play a driving role in the seasonality of COVID-19 outbreaks. The timing of COVID-19 incidence outbreaks was not affected by vaccination campaigns, and did not directly correlate with public holidays or environmental factors, said study co-author Kezhong Zhang, Ph.D., a professor of Biochemistry, Microbiology and Immunology and of Molecular Medicine and Genetics.
The study has immediate implications for both public health professionals and the public at large in understanding and preparing for future COVID-19 surges.
In Seasonality of COVID-19 incidence in the United States, published in the journal Front Public Health, they outline a predictable seasonality of COVID-19 outbreaks in the U.S. The seasonality is characterized by the waves of COVID-19 incidence occurring three times a year.
The team collected daily county-level COVID-19 incidence data across the contiguous U.S. for three full seasonal years, from March 2020 to March 2023. The data was sourced from reliable databases such as 1Point3Acres and The New York Times, which are known for accurate, real-time updates of COVID-19 cases and deaths. The core methodology the authors employed in the study was spectral analysis using Fast Fourier Transform algorithms.
Our findings of tri-annual peaks in COVID-19 outbreaks could be very useful in public health preparedness. For instance, authorities can allocate resources more effectively and implement targeted public health interventions to counter anticipated surge periods, Dr. Zhang said.
However, it is important to recognize that though the public health/social/environmental factors did not affect the timing of the outbreaks, they likely have a significant impact in the amplitude of each outbreak. For example, vaccination and social distancing/mask-wearing efforts are the likely reason for significantly lower amplitudes of each outbreak in the second year of the pandemic (2021-2022) compared to the first year (2020-2021).
Class of 2023 graduate El Hussain Shamsa, M.D., an Internal Medicine resident at Case West Western/University Hospitals in Cleveland, contributed to study, including while working Dr. Zhangs lab as a medical student at WSU.
The study first acknowledges a debate over whether COVID-19 disease incidence follows a seasonal pattern like many other respiratory viral infections, such as influenza. The identification of seasonality of COVID-19 is crucial for infection control as it can guide public health prevention measures.
The publication and the related results were featured by Medicine Innovates as a research breakthrough, and the article Seasonal Patterns and Periodicity of COVID-19 Outbreaks in the United States: Discoveries from a Spectral Analysis Study.
Once upon a time, COVID-19 was two weeks of coughing and an inability to smell your new candle. Then we discovered the existence of Long COVID a vague conglomeration of more than 200 symptoms that can be debilitating months or even years after the original disease seems to have cleared up.
Now, four years into the pandemic, were still not totally sure whats behind the extended condition but a new study that followed 24 Covid patients over a period of up to 900 days has revealed a potential factor that has previously gone unnoticed: your T cells.
Its not the first study to link COVID-19 with these particular immune cells only last month, a study from Imperial College London hinted at the potential for targeted T cell therapies to fight the condition. But it is one of the longest-running: it was set up in 2020, long before the idea that COVID-19 might hang around in the body was widely accepted.
Thats not all that sets it apart, however. The team behind the study was inspired by their experience researching HIV a disease practically defined by its ability to kill T cells. Unable to monitor antibodies so early into the pandemic, they instead used PET scans to study the behavior of T cells inside the body after infection.
[It] is a novel approach [] that allows them to map activated T cells in the body, explained Danny Altmann, Professor of Immunology at Imperial College London, co-author of the Penguin Handbook of Long Covid and lead investigator of the NIHR WILCO LONG COVID Study, who was not involved in the study.
They find patterns of long-term T cell activation that may help to explain patterns of Long Covid symptoms, he said. For example, people with respiratory symptoms showed long-term homing of activated T cells to the lung.
Other scans showed activated T cells swarming to the gut wall, prompting the team to analyze gut biopsies. Again, they found the presence of COVID-19 RNA a long-term virus reservoir, Altmann explained.
The finding was even more stark when compared to six control samples scans from before the pandemic, before anybody on the planet couldve possibly had this virus, Michael Peluso, assistant professor of medicine at the University of California, San Francisco, and lead author of the paper, told Stat. While T cells were activated in these scans, they were concentrated where youd expect the liver, kidneys, and other places known to help clear inflammation. In the Long Covid patients, they were everywhere.
Its really striking, Peluso said. Oh, my goodness, this is happening in someones spinal cord, or their GI tract, or their heart wall, or their lungs.
While the study isnt a slam-dunk its not actually certain what the T cells are reacting to, and the researchers arent sure whether the scans are showing remnants of old infections, or active virus particles its nevertheless alluring. There has been a large amount of inferential data supporting a view that a key factor underpinning Long Covid may be that some people do not properly clear the virus and harbor reservoirs of SARS-CoV-2 in their tissues, Altmann noted but its been hard to prove.
In that respect, this study should be seen as a significant step in advancing our understanding of this disease process, he said, and thus shifting nearer to treatments that could offer hope to the tens of millions of patients.
At a time when theres desperate need for new clinical trials, studies like this help to point the way.
The study is published in the journal Science Translational Medicine.
This transcript has been edited for clarity.
ACIP, the CDC's Advisory Committee on Immunization Practices, met for 3 days in June. New vaccines and new recommendations for respiratory syncytial virus (RSV), flu, COVID, and a new pneumococcal vaccine were revealed.
We'll begin with RSV vaccines for adults aged 60 or older. For this group, shared clinical decision-making is out; it no longer applies. New, more specific recommendations from ACIP for RSV vaccines are both age based and risk based. The age-based recommendation applies to those aged 75 or older, who should receive a single RSV vaccine dose. If they have already received a dose under the old recommendation, they don't need another one, at least for now.
The risk-based recommendation applies to adults from age 60 up to 75, but only for those with risk factors for severe RSV. These risk factors include lung disease, heart disease, immunocompromise, diabetes, obesity with a BMI of 40 or more, neurologic conditions, neuromuscular conditions, chronic kidney disease, liver disorders, hematologic disorders, frailty, and living in a nursing home or other long-term care facility. Those aged 60-75 with these risk factors should receive the RSV vaccine, and those without them should not receive it. The best time to get the RSV vaccine is late summer, but early fall administration with other adult vaccines is allowed and is acceptable.
Vaccine safety concerns were top of mind as ACIP members began their deliberations. Possible safety concerns for RSV vaccines have been detected for Guillain-Barr syndrome, atrial fibrillation, and idiopathic thrombocytopenic purpura. Safety surveillance updates are still interim and inconclusive. These signals still need further study and clarification.
Two RSV vaccines have been on the market: one by Pfizer, called Abrysvo, which does not contain an adjuvant; and another one by GSK, called Arexvy, which does contain an adjuvant. With the recent FDA approval of Moderna's new mRNA RSV vaccine, mRESVIA, there are now three RSV vaccines licensed for those 60 or older. Arexvy is now FDA approved for adults in their 50s. That just happened in early June, but ACIP doesn't currently recommend it for this fiftysomething age group, even for those at high risk for severe RSV disease. This may change with greater clarification of potential vaccine safety concerns.
There is also news about protecting babies from RSV. RSV is the most common cause of hospitalization for infants in the United States, and most hospitalizations for RSV are in healthy, full-term infants. We now have two ways to protect babies: a dose of RSV vaccine given to mom, or a dose of the long-acting monoclonal antibody nirsevimab given to the baby. ACIP clarified that those who received a dose of maternal RSV vaccine during a previous pregnancy are not recommended to receive additional doses during future pregnancies, but infants born to those who were vaccinated for RSV during a prior pregnancy can receive nirsevimab, which is recommended for infants up to 8 months of age during their first RSV season, and for high-risk infants and toddlers aged 8-19 months during their second RSV season.
Last RSV season, supplies of nirsevimab were limited and doses had to be prioritized. No supply problems are anticipated for the upcoming season. A study published in March showed that nirsevimab was 90% effective at preventing RSV-associated hospitalization for infants in their first RSV season.
Here's what's new for COVID vaccines. A new-formula COVID vaccine will be ready for fall. ACIP voted unanimously to recommend a dose of the updated 2024-2025 COVID vaccine for everyone aged 6 months or older. This is a universal recommendation, just like the one we have for flu. But understand that even though COVID has waned, it's still more deadly than flu. Most Americans now have some immunity against COVID, but this immunity wanes with time, and it also wanes as the virus keeps changing. These updated vaccines provide an incremental boost to our immunity for the new formula for fall. FDA has directed manufacturers to use a monovalent JN.1 lineage formula, with a preference for the KP.2 strain.
Older adults (aged 75 or older) and children under 6 months old are hit hardest by COVID. The littlest ones are too young to be vaccinated, but they can get protection from maternal vaccination. The uptake for last year's COVID vaccine has been disappointing. Only 22.5% of adults and 14% of children received a dose of the updated shot. Focus-group discussions highlight the importance of a physician recommendation. Adults and children who receive a healthcare provider's recommendation to get the COVID vaccine are more likely to get vaccinated.
On June 17, 2024, a new pneumococcal vaccine, PCV21, was FDA approved for those aged 18 or older under an accelerated-approval pathway. ACIP voted to keep it simple and recommends PCV21 as an option for adults aged 19 or older who currently have an indication to receive a dose of PCV. This new PCV21 vaccine is indicated for prevention of both invasive pneumococcal disease (IPD) and pneumococcal pneumonia. Its brand name is Capvaxive and it's made by Merck. IPD includes bacteremia, pneumonia, pneumococcal bacteremia, and meningitis.
There are two basic types of pneumococcal vaccines: polysaccharide vaccines (PPSV), which do not produce memory B cells; and PCV conjugate vaccines, which do trigger memory B-cell production and therefore induce greater long-term immunity. PCV21 covers 11 unique serotypes not in PCV20. This is important because many cases of adult disease are caused by subtypes not covered by other FDA-approved pneumococcal vaccines. PCV21 has greater coverage of the serotypes that cause invasive disease in adults as compared with PCV20. PCV20 covers up to 58% of those strains, while PCV21 covers up to 84% of strains responsible for invasive disease in adults. But there's one serotype missing in PCV21, which may limit the groups who receive it. PCV21 does not cover serotype 4, a major cause of IPD in certain populations. Adults experiencing homelessness are 100-300 times more likely to develop IPD due to serotype 4. So are adults in Alaska, especially Alaska Natives. They have an 88-fold increase in serotype 4 invasive disease. Serotype 4 is covered by other pneumococcal vaccines, so for these patients, PCV20 is likely a better high-valent conjugate vaccine option than PCV21.
What's new for flu? Everyone aged 6 months or older needs a seasonal flu vaccination every year. That's not new, but there are two new things coming this fall: (1)The seasonal flu vaccine is going trivalent. FDA has removed the Yamagata flu B strain because it no longer appears to be circulating. (2) ACIP made a special off-label recommendation to boost flu protection for solid organ transplant recipients age 18 through 64 who are on immunosuppressive medications. These high-risk patients now have the off-label option of receiving one of the higher-dose flu vaccines, including high-dose and adjuvanted flu vaccines, which are FDA approved only for those 65 or older.
