Reinfection 101
Our RIVER protocol: prevention, preparation and care
Most people reading this will know that Covid-19 is not just a mild respiratory infection without risk. Repeated infections can carry significant health risks, including Long Covid, and for those already living with chronic illness, reinfection can be devastating. Yet public health messaging and access to preventative measures disappeared with ‘Freedom Day’, and it could be argued that they were never there in the first place, especially for Long Covid. This abandonment by the state has left individuals and families to navigate these risks largely alone.
So, we have prepared a quick access 101 Reinfection Guide of the RIVER protocol, available below or as a PDF download. We already have a webpage on what to do if reinfected, with ready-to-go checklists, references and instructions. To supplement this, there is also this article!
The RIVER Reinfection Protocol
The RIVER protocol is a practical framework developed by us to help you prepare for Covid-19 reinfection, and it also applies for other infectious viral illnesses. The risk of long-tail symptoms and ME arises from other viruses, especially EBV. Our society, unlike Southeast Asia, has a horrible habit of presenteeism without any mitigations to stop infecting others. This cultural shift did not happen in the pandemic, and an opportunity was lost.
We believe that being prepared, knowing what to do and having an emergency box ready can help you rest and reduce risk for yourself and others as soon as symptoms occur. It is simply:
R - Rest
I - Isolate
V - Ventilate
E - Emergency Box
R - Reduce Viral Load
Please note this protocol is not a clinically validated treatment programme and cannot guarantee prevention of complications or recovery. It is community-sourced and has had to be formed due to a failure in public health to help you make informed decisions.
R = Rest
Rest is particularly important for people with Long Covid or ME, especially those who experience PEM. It also allows everyone to give their system and immune system the maximum chance to recover, so the body’s resources can concentrate on fighting the infection and symptoms can be managed.
Practical measures include:
Rest, pace & avoid overexertion
Prioritise sleep
Stay home if unwell
Test multiple times (PCR ideally)
Reduce stimulation
Use aids & support if needed
Please don’t try and exercise your way through symptoms or push through symptom exacerbation. This includes the period after infection too, we have heard too many stories of people triggering Long Covid through exercising too soon.
I = Isolate
SARS-CoV-2 is an airborne virus, and it has been shocking at how this has been so controversial and avoided as a fact throughout the pandemic. The UK Covid Inquiry finally confirmed this - but it still hasn’t filtered through to public recognition.
In the spirit of the Japanese concept of Wa, or harmony, which drives their cultural taboo of exposing others to illness, reducing contact with others during an infection can help protect household members, carers and the wider community.
Where possible:
Stay home
Isolate from household if possible
Use well-fitting respirators (N95, FFP3)
Inform others you are sick
Please note that a single negative rapid antigen test does not reliably exclude COVID-19, particularly early in an infection. PCR testing at home is possible with a Pluslife mini dock and can give a more reliable indication.
Isolation can be particularly difficult for people who rely on carers or family members. Planning ahead can help reduce exposure without compromising essential care. It can be very useful to discuss with those around you the protocol you would like to be established if infection is present.
V = Ventilate
Improving indoor air quality is a vital part of reducing transmission. Ventilation helps dilute and remove infectious particles, while appropriately sized HEPA filtration can remove airborne particles from indoor air. The UV in sunlight can also sanitise viruses in the air or on surfaces.
Practical measures include:
Open windows
Use HEPA filtration
No recirculated air
Monitor CO2, <800pmm
Shock ventilation: open windows & doors wide for short periods.
A CO₂ concentration below 800 ppm if possible
Ventilation and filtration work best alongside other precautions, particularly well-fitting respirators. One can measure CO2 through a monitor, one of the most well-known and high-quality ones is the portable Aranet.
E = Emergency Box
Preparing supplies before becoming unwell can make an enormous difference, particularly for people with limited energy, cognitive impairment or severe chronic illness. You can also ask someone to prepare this for you.
Our RIVER protocol includes two emergency-box options. We seriously think that those who protect their health and others, especially if anyone is clinically vulnerable, is a superhero, so we’ve dedicated these to the marvellous. It’s also helpful framing if there are younger members in the household to reinforce the positive nature of protecting others.
The X-Men Box
This is designed for people who can isolate while retaining access to household facilities.
Suggested contents include COVID-19 tests, a thermometer, pulse oximeter, medications already prescribed or agreed with a clinician, hydration supplies, respirator masks, symptom-relief items and emergency contact information. The full list is on our website.
We also have a printable checklist, so you can refill and prep at any time. There is also a reference list of the top studies for the prevention methods suggested. If you wish to have a label that includes an emergency contact list you can access that here too.
The Wonder Woman Box
This is for people who have limited access to shared household facilities or need a greater degree of independence while isolating, especially if clinically vulnerable.
It includes the essentials from the X-Men Box alongside items such as a kettle, drinking-water container, easy-to-prepare meals, utensils, cleaning supplies, personal hygiene products and additional comfort items. Again, the full list is available here.
For people with severe Long Covid or ME, preparing these supplies may be physically impossible without assistance. We encourage family members, friends and carers to take on the physical and mental labour to help prepare boxes in advance, respecting the individual’s needs and energy limitations.
This box also has a checklist, reference guide and label.
R = Reduce Viral Load
Once infection has occurred, however, interventions intended to reduce viral replication or the amount of virus present in the body require careful consideration.
These are not interchangeable approaches, and evidence varies considerably. But this is due to the lack of research, so within the community, a certain amount of experimentation has happened.
Antiviral treatments
For certain people at higher risk of severe COVID-19, antiviral treatments such as nirmatrelvir/ritonavir (Paxlovid) may reduce the risk of hospitalisation and serious illness. Eligibility is restricted under NHS guidance, and treatment must begin promptly after symptom onset. To see if you qualify and how to access help you can see the NHS page here. Paxlovid also has important drug interactions and contraindications, making clinical assessment essential.
Nasal sprays and mouthwashes
Various nasal sprays and mouthwashes have been investigated for their potential effects on SARS-CoV-2, including products containing iota-carrageenan, nitric oxide and cetylpyridinium chloride.
Although some laboratory and clinical findings are encouraging, evidence remains insufficient to establish that these products reliably prevent infection, reduce transmission or prevent Long Covid. We have compiled the research on these in our reference download.
Medications and supplements
A range of medications and supplements have been investigated for potential roles in COVID-19, including metformin, antihistamines, melatonin, aspirin, vitamin D, zinc and other compounds.
However, the quality and strength of evidence vary considerably. Some findings relate to specific populations, treatment windows or outcomes and cannot be generalised to everyone.
For example, metformin has shown promising results for reducing Long Covid incidence in a particular clinical trial population. Other substances, including nattokinase and aspirin, may carry significant risks such as bleeding or interactions with prescribed medication, so seeking appropriate professional advice is advised.
There still remains an urgent need for high-quality biomedical research and accessible, evidence-based treatments, and the acknowledgement that people with Long Covid are clinically vulnerable and should be treated accordingly, with access to the NHS vaccination program.
Recognising red flag symptoms
Although many COVID-19 infections can be managed at home, some symptoms require urgent medical attention, and it is good to be prepared to recognise these.
Warning signs include:
Significant or worsening breathlessness.
Chest pain.
New confusion or altered consciousness.
Fainting or collapse.
Persistent vomiting or inability to retain fluids.
Signs of dehydration.
Persistent or worsening fever.
New unilateral leg swelling or pain, particularly alongside breathlessness.
Any severe or rapidly deteriorating symptoms.
For most adults, oxygen saturation readings of 93–94% warrant urgent clinical assessment, while readings of 92% or below may indicate an emergency. Individual clinical circumstances and baseline readings matter, and pulse oximeters have limitations, especially for darker-toned skin.
In the UK, contact NHS 111 or your clinical team for urgent advice, and call 999 for life-threatening symptoms. Do not delay seeking help because a Covid-19 test is negative or an oxygen reading appears normal.
Reducing the risk of future reinfections
Prevention remains the most effective way to avoid the risks associated with another infection. We encourage a layered approach:
Wear a well-fitting FFP3 or N95 respirator mask.
Improve indoor air quality through ventilation and filtration.
Keep up to date with COVID-19 vaccination where eligible and appropriate.
Avoid close contact with people who are unwell.
Encourage household members and visitors to take precautions.
Make a household infection plan before anyone becomes ill.
These measures are particularly important where someone is clinically vulnerable, immunocompromised or already living with Long Covid or ME.
They are also measures that schools, employers, healthcare providers and public institutions should support, but we know in reality this is far from the case.
Prevention is healthcare
For too long, the responsibility for avoiding COVID-19 has fallen disproportionately on individuals, including those least able to protect themselves.
People living with Long Covid, ME/CFS and other chronic illnesses should not have to choose between accessing healthcare, education, employment and protecting their health.
Clean indoor air, accessible vaccination, infection-conscious healthcare, appropriate masking and effective public health communication are not unreasonable demands.
They are essential components of an inclusive and evidence-based approach to public health.
Avoiding reinfection is not about living in fear. It is about recognising preventable risks, protecting health and ensuring that everyone can participate in society as safely as possible.
Our RIVER protocol is one practical contribution to that effort.
Why is avoiding COVID-19 reinfection important?
As the acute severity of COVID-19 has generally declined, a misleading narrative has emerged that the pandemic is over, and that repeated infections are harmless or simply an unavoidable part of everyday life. However, we beg to disagree. Research continues to demonstrate that SARS-CoV-2 can have consequences extending far beyond the initial infection. It is simply an inconvenient narrative that is easier and cheaper to ignore in a capitalist, individualistic society.
In October 2026, The New York Times explored the risks of repeated infections, interviewing leading researchers including Professors Ziyad Al-Aly, Akiko Iwasaki and Danny Altmann. Their message was clear: although prior infection and vaccination can reduce the likelihood of severe acute illness, they do not eliminate the possibility of lasting harm. Why is that?
1. Every infection carries a risk of Long Covid
Long Covid can develop following mild, severe or even initially asymptomatic infections. Importantly, having recovered from a previous infection does not guarantee protection against Long Covid following another.
A 2026 nationwide Danish cohort study involving more than 4.4 million people found that reinfection was associated with an increased risk of a recorded Long Covid diagnosis. At 180 days, the absolute risk was 0.73% after one infection compared with 1.16% after two infections.
These figures reflect diagnoses captured in healthcare records rather than the full burden of Long Covid, which is likely to be under-recognised.
2. Reinfections may contribute to cumulative health risks
SARS-CoV-2 infection has been associated with complications affecting the cardiovascular, neurological, respiratory, gastrointestinal, renal and endocrine systems.
A 2025 study examining multisystem consequences of reinfection found a 21% higher relative risk of post-acute sequelae associated with reinfection, alongside increased risks across several organ systems. This challenges the assumption that repeated infections are medically inconsequential.
3. Reinfection can be a risk for people with Long Covid and ME
For those already living with Long Covid, ME or other chronic conditions, another infection can bring additional uncertainty. Some people report deterioration in existing symptoms, new symptoms or a reduction in their functional capacity following reinfection. A recent study by Visible and the Patient-Led Research Collaborative in Nature also linked worse symptoms after infection.
This is particularly important for those experiencing post-exertional malaise (PEM), dysautonomia, orthostatic intolerance or severe functional impairment.
The consequences of deterioration can be profound, affecting independence, employment, education and the ability to carry out basic activities of daily living. Preventing infection is therefore not simply about avoiding a few days of acute illness. For some, it is about protecting an already fragile level of health and functioning.
4. Vaccination is important, but not sufficient
Vaccination remains an important measure for reducing the risk of severe acute COVID-19 and can reduce the risk of Long Covid.
However, vaccination does not provide complete protection against infection or post-acute sequalae. It is also reported in the community that some with Long Covid and/or ME have complications with vaccines, creating a horrible double-edged sword of risk management, primarily because research has not been adequate in this area and there is no access to other options like Novavax in the UK.
This is why a layered, holey Swiss cheese approach adapted by Dr Ian MacKay remains essential, particularly for clinically vulnerable people and those seeking to avoid reinfection.
Effective precautions include well-fitting respirator masks, improved ventilation, HEPA air filtration, avoiding unnecessary exposure and ensuring people with symptoms stay away from others.
Infection prevention is a collective responsibility, not simply an individual lifestyle choice.
Disclaimer: This article provides general educational information and is not a substitute for individual medical advice. Evidence and treatment recommendations may change. Consult a qualified healthcare professional regarding treatment suitability, contraindications and interactions.
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