November 8th, 2021
North Carolina is back to relative normalcy in most places.
If you have had 2 doses of an mRNA vaccine, you have a very very small risk of a significant hospitalization and therefore death from the Delta variant based on statistics overall.
Being Unvaccinated now is the greatest risk factor for a negative outcome. Advancing age and co morbid disease add layers of risk on top of the vaccination status
We are continuing to see that all other variants are not an issue yet and likely will not be in the United States as delta is outcompeting them.
As it stands today, the United States has had 46.2 million known cases and almost 750,000 deaths. There continues to be a significant downtick in deaths over the previous 2 week cycles as case volume has plummeted.
If you did not read the newsletter about an Integrative approach to health in the COVID era, read this link and this link.
As with the first newsletter on this topic, keep solace with the fact that there is a 99+% chance of survival for all of us regardless of vaccination. However,
mathematically, you now have a 99.9998% chance of survival once vaccinated and the vaccine safety for the mRNA vaccines continues to look good.
Why take on that extra risk?
Coronavirus Update 48
Repeated: According to the American Medical Association, 96% of medical doctors have received a Covid vaccine nationally. That says a lot about the safety of this vaccine. Physicians are loathe to receive interventions that have not been well studied for safety as we see the train wrecks of intervention failures in our patients. This information should really help those that have been sent down the wrong path by the poor political messaging around vaccination nationally. If you are over 18 years of age, please consider vaccinating if you have not already done so. This decision may save your life.
Quick Hits -
1) A new and fascinating study in Nature has looked at the time of day in relation to immune cell activity which could be and likely is critical to how we respond to pathogens in nature as well as vaccines in general. The science: there are cells called dendritic cells which can migrate around the body to capture and then present protein fragments from pathogens and other proteins sources to professional immune cells called T cells for immune training and pathogen killing. The circadian timing or rhythm is essentially the way our systems react to the time of day that corresponds to the rise and fall of the sun. The animal model studied is the mouse which is a nocturnal creature so results will be opposite of what we as humans would expect to see.
The group found that the dendritic cells migrate from the skin to the lymphatic vessels and on to the lymph nodes most often during our early morning time after sleep has finished. (Holtkamp et. al. 2021) What we can glean from this study is this, we as humans have evolved to be most functional immunologically and metabolically when our bodies follow the rise and fall of the sun. If we stay up all night and sleep during the day, we are flipping nature on its head with negative consequences likely as has been shown epidemiologically through study in night shift workers. My idea is this. Don't ever take a vaccine after being up all night from work or bad sleep. Make sure that you are in balance with your circadian rhythms before challenging your immune system in any way.
2) If you had an mRNA vaccine or the Astra Zeneca variety and then contract the delta strain of SARS2, your risk of spreading the virus to others is roughly half as great as a non vaccinated person. However, that protection only lasts about three months. Again, this is only if you get the breakthrough delta infection. The vaccine is preventing breakthroughs at a great rate. The take home point is that once vaccinated, your risk of a breakthrough infection remains low, but if you have one, you are very likely to spread it just like the unvaccinated 3 months after dose 2. (Eyre et. al. 2021)
3) Syra Madad, Monica Gandhi and Ashish K. Jha wrote an article in WaPo back in April with a key piece of the when do we change course and live with COVID reality. "As clinicians and epidemiologists, we see the tipping point at which restrictions like masks and social distancing can be lifted by looking at two parameters: 1) severe disease from covid-19 as represented by hospitalizations and 2) vaccination rates. The goal for hospitalizations from covid-19 should be less than 5 cases per 100,000 people, or about 16,000 hospitalizations in the nation."" This is lower than the hospitalization rates from influenza during the height of the flu season, which normally shows an average of 20 to 40 hospitalizations per 100,000 people, but mortality for hospitalized covid patients remains very high. Further, the coronavirus vaccines are all much more effective than the current influenza vaccines. And as such, the Israeli experience suggests that once we manage to get at least 40 percent of people at least one dose, we can expect substantial and sustained drops in infection rates. Of course, this percentage will be influenced by other factors, such as the underlying rate of immunity from previous infections. It’s important to look at these quantitative numbers as key metrics for easing restrictions in each state. It will be a gradual process based on data, not dates. States will need to continue to be nimble and vary restrictions accordingly during this transition phase of vaccine rollout." (Madad et. al. 2021)
This article was written before delta was the main player, however, the principles are still the same. As of today, vaccination rates are climbing with 221 million Americans vaccinated with one dose and a further 193 million fully vaccinated and 19 million booster doses given for higher risk groups. That means that the risk of hospitalization and death nationally is significantly lower than at any time in the pandemic. Data is data and this vaccination rate although not perfect is great for reducing hospital overload due to covid. There are many that are still spinning this as a mess with the influenza virus on the way. That we need to remain masked, distanced and other early pandemic policies. To them, I say, let's keep a positive vaccine message and also a healthy lifestyle message that gives us control over our health so that our immune systems are well maintained for the next 100 years as the influenza and now SARS2 viruses are with us forever. Let us follow science based guidelines for masking and distancing as the thoughtful authors above have done. Politicians should not be making these decisions willy nilly anymore.
Strong Opinion: It is very clear to me now that the country needs to prioritize the health of children through quality nutrition and support in school. There are no more acceptable excuses for remote learning, poor education and poor nutrition for our future generations of leaders and workers. In person learning is the only way to teach our grade school children full stop. My tone is stern and I am fully aware of it. I feel that strongly about our children's health. With a 1.7 trillion budget plan being discussed in congress, how is incredible school food not priority number one? It would be, if I were in the White House. Education and nutrition would be the main priorities for all Americans through college well before discussing military, foreign aid, and social programs. If we set a goal to make absolutely sure that every child from age 0 to 21 never has to think about quality food and quality education, we would be well on our way to a great society. What I could do with 1.7 trillion dollars, incredible! For more see section II below on school closure.
4) From the CDC executive summary: Available evidence shows that fully vaccinated individuals and those previously infected with SARS-CoV-2 each have a low risk of subsequent infection for at least 6 months. Data are presently insufficient to determine an antibody titer threshold that indicates when an individual is protected from infection. At this time, there is no FDA-authorized or approved test that providers or the public can use to reliably determine whether a person is protected from infection.
• The immunity provided by vaccine and prior infection are both high but not complete (i.e., not 100%).
• Multiple studies have shown that antibody titers correlate with protection at a population level, but protective titers at the individual level remain unknown.
• Whereas there is a wide range in antibody titers in response to infection with SARS-CoV-2, completion of a primary vaccine series, especially with mRNA vaccines, typically leads to a more consistent and higher-titer initial antibody response.
• For certain populations, such as the elderly and immunocompromised, the levels of protection may be decreased following both vaccination and infection.
• Current evidence indicates that the level of protection may not be the same for all viral variants.
• The body of evidence for infection-induced immunity is more limited than that for vaccine-induced immunity in terms of the quality of evidence (e.g., probable bias towards symptomatic or medically-attended infections) and types of studies (e.g., observational cohort studies, mostly retrospective versus a mix of randomized controlled trials, case-control studies, and cohort studies for vaccine-induced immunity). There are insufficient data to extend the findings related to infection-induced immunity at this time to persons with very mild or asymptomatic infection or children.
• Substantial immunologic evidence and a growing body of epidemiologic evidence indicate that vaccination after infection significantly enhances protection and further reduces risk of reinfection, which lays the foundation for CDC recommendations. (CDC)
The CDC has put quality information into this summary. Two caveats remain up for debate. If you had natural infection, one dose of an mRNA vaccine appears to be the answer to great immunity based on the data unless you have known inability to have a solid vaccine response which occurs with elderly age, severe inflammation based obesity, immunocompromised status and some rare genetic variants of immune response. Second, variants are not more deadly once vaccinated, yet.
5) Vaccinate the 5 to 12 age range - does the dose matter if your child is on the cusp of age 12? Five experts in immunology answer the question in this article. The long and short in these experts minds is to vaccinate as soon as possible regardless of dose given. This age group has an exceedingly low risk of MIS and/or severe acute disease but that number is not zero, so each parent or guardian must decide to risk this small chance of illness or vaccinate. It is that simple.
6) Opinion, in the South, we are now a few months into packed stadiums, concerts and other indoor/outdoor mass human events and we are in a good place overall with covid numbers. This is the first and largest sign that we are quite far down the path of returning to normalcy. I have personally been to many of the above events both in and outdoors. Delta is still the same animal, so we are moving closer to having enough people with quality immunity to prevent big outbreaks.
I was at a coffee shop the other day and was chastised for not wearing a mask when I walked in, yet 90% of the rooms occupants were unmasked because they were "dining" or "drinking coffee". You cannot make this stuff up. Comedy. We need to follow some logical reasoning when applying science to decision making.
7) More on risk of breakthrough issues once vaccinated. From New York State's Department of health: As of data received through October 24, 2021, the New York State Department of Health is aware of:
• 120,653 laboratory-confirmed breakthrough cases of COVID-19 among fully-vaccinated people in New York State, which corresponds to 1.0% of the population of fully-vaccinated people 12-years or older.
• 8,114 hospitalizations with COVID-19 among fully-vaccinated people in New York State, which corresponds to 0.07% of the population of fully-vaccinated people 12-years or older.
These results indicate that laboratory-confirmed SARS-CoV-2 infections and hospitalizations with COVID-19 have been uncommon events among the population of people who are fully-vaccinated (≥14 days after completing their vaccine series).
This data set is clear that 7 per 10,000 persons will be hospitalized with COVID once fully vaccinated. They do not give any death data, but we know that it will another log fold less. The other piece of data missing is the age group of the admitted which likely skews older significantly based on other data sets to date as well as known immune activity with age.
8) Variants - There are 10 being monitored by the CDC. Only Delta is a variant of concern and there are no variants of high consequence. All previously discussed variants have faded out. Here are the only two new ones with possible but mostly meaningless interest.
a) A30 is a new variant from Africa noted in the spring of 2021. It has some significant ability to evade the vaccine via spike protein mutations. However, it has little capacity to outcompete delta making it a non issue to date. (Arora et. al. 2021)
b) AT.4.2 is a sub lineage of delta that is circulating in a few states. It has marginally increased infectivity, but no increased morbidity and remains not concerning at this time.
9) Read this article as it is brief and prepare for next Covid newsletter. Link
Get back to living with spunk and vigor,
Dr. M
Holtkamp Nature Immunology
Mallapaty Nature News
Eyre MedRxIV
Madad Washington Post
NYS Health Department
Arora Nature Cellular and Molecular Immunology
CDC MMWR
CDC Variants Page
