January 25th, 2021
Long one this week.
Lots of facts and opinion!

It is TIME!
Back to School!

RESULTS:

Over 9 weeks, 11 participating school districts had more than 90,000 students and staff attend school in-person; of these, there were 773 community-acquired SARS-CoV-2 infections documented by molecular testing. Through contact tracing, NC health department staff determined an additional 32 infections were acquired within schools. No instances of child-to- adult transmission of SARS-CoV-2 were reported within schools.
CONCLUSIONS: In the first 9 weeks of in-person instruction in NC schools, we found extremely limited within-school secondary transmission of SARS-CoV-2, as determined by contact tracing. (Zimmerman et. al. 2021)

Crowds, indoor environments, poor ventilation and TIME remain the recipe for a negative COVID19 outcome based on your personal risk of metabolic disease and genetic weakness for viral surveillance.

Latest numbers google/CDC show that cases peaked in early January and continue to trend down. It appears that the holiday damage may be finished as far as case explosions. California suffers the worst worldwide rates to date. North Carolina had the last peak on January 5th. Death rates still remain significantly less per infection than seen earlier in the pandemic which is a continued blessing but the volume of total cases is driving higher death numbers overall.

As it stands today, the United States has had 25 million cases and almost 414,000 deaths.

There is still no change in the knowledge that more than 80% of deaths are skewed toward the over 55 age group and 94% of all deaths occurred in a person with a co-morbid chronic health disease. More biological antibody medicines are on the horizon that may along with a mixture of vitamin A , D, zinc, quercetin and melatonin be employed for a safe resolution to COVID19. 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.

We are at the stage of the pandemic where it has dragged on too long for all sides and all interests. This was an expected reality. You see the fight on all sides to keep schools virtual or not. To close business or open everything. To vaccinate or not. You see completely different viewpoints following demographic lines. We must maintain open minds to all sides of these debates and discussions. Compromise is key.

In my mind we should be back in school for at least K through 8 where the risk of transmission is very very small but the downstream risks of virtual learning to our children is very high. We should help the national cause by all wearing masks in crowded environments. We should limit larger gatherings as the volume of cases is still very high. We hope that the government helps the public school systems open safely.

The other big change in the thought calculous now comes in the form of survivor biased issues. Death from SARS2 is improving, but chronic post illness issues are increasing. In this newsletter we will look at some of these risks and how they have really made the case to vaccinate stronger.

I am officially vaccinated. A little soreness at the injection site for a few days, nothing more. I hope that my choice helps you feel more comfortable with your decision. No matter your decision, at least you are making it from a position of knowledge. The sooner we get more vaccines into more arms, the sooner we return to a reasonably normal life. I am very hopeful for a return to semi normal life this summer. Fingers crossed.

A really nice predictive essay from McKinsey and Company is worth your time.

New COVID Quick Hits !

1) Autoimmunity risk is real! What is the immunological reality if you get the wild type infection versus the mRNA vaccine? Earlier this year there were studies that showed an increased risk of autoimmunity in persons recovering from SARS2/COVID19. This is a known and mechanistically makes sense as COVID is an inflammatory disease that can leave our cells available for auto presentation based on our immunological status pre and during the infection. (Woodruff et. al. 2020)(Lerma et. al. 2020)(Vojdani et. al. 2020)(Kanduc et. al. 2020)

Wild type infection will challenge our immune system by allowing it to see many protein pieces of the virus as it replicates and spreads throughout our tissues. The vaccine on the other hand is only presenting the one spike protein to the immune system after the messenger RNA teaches our cells to make the proteins and the immune system produces antibodies to it. This is only one viral protein type or epitope that the immune system can cross react with against our self tissue.

Restated another way, the true SARS2/COVID19 infection causes a ton of inflammatory tissue damage coupled with exposure to all of the SARS2 protein structures that the virus has including the many different spike proteins, envelope, membrane and the nucleocapsid. (SARS2 proteins) All of these proteins have the possibility of being structurally similar enough to our native tissue that we develop auto antibodies. The generation of antibodies against self tissue is the beginning stage of all autoimmune disease.

Remember that females are 7 times more likely to develop autoimmune disease in general and that SARS2 attacks males more aggressively based on our relative lack of interferons and antibodies against interferons. What the final tally will be risk wise between men and women will be interesting but will not affect my decision.

At this point, we stand again at a fork in the road. No treatment is perfectly safe and that is certainly true of a new, novel technique no less, vaccine. Go left for wild type disease and autoimmune risk that is significant based on the research or go right and run the theoretical risk of autoimmunity to one singular protein if it occurs at all. I am a firm believer in choice. I know my choice. Now you are armed with more data and can get closer to making your own if you have not already. (Kostoff et. al. 2020)

2) Developing natural immunity from wild type SARS2 disease may not occur in the long run. This is really a frustrating reality as that was at least a partial hope for earlier rather than later pandemic resolution. From the Journal Cell, Dr. Kaneko and colleagues write: "These data identify defective Bcl-6+ TFH cell generation and dysregulated humoral immune induction early in COVID-19 disease, providing a mechanistic explanation for the limited durability of antibody responses in coronavirus infections, and suggest that achieving herd immunity through natural infection may be difficult. (Kaneko et. al. 2020) (Woodruff et. al. 2020) We have seen that many individuals lose antibodies to SARS2 spike protein relatively rapidly within months of infection leaving them at risk for reinfection.

Developing immunity from the mRNA vaccines appear legitimate. (Lederer et. al. 2020) So far we have a significant unknown reality. Do we, in general, get some immunity from natural infection despite waning antibodies through T cell and memory B cell activity? The data to date says yes to this likelihood despite the waning antibodies as stated above. The next question is? How long does the mRNA immunity last? Moderna is on record as saying that they are predicting north of 12 months and maybe significantly longer.

We will have to track this data closely over the next few years as this is where the rubber meets the road for herd immunity and returning to a normal life.

3) Finally, a strong scientific statement from a group out of Stanford University that lockdowns are ineffective as a tool against COVID and pandemics in general. They conclude, "While small benefits cannot be excluded, we do not find significant benefits on case growth of more restrictive NPIs. Similar reductions in case growth may be achievable with less restrictive interventions." (Bendavid et. al. 2021) This study reinforces all of the data to date that restrictive non pharmaceutical measures are NOT an added benefit over masking, social distancing and pharmaceutical support.

This study essentially tells us that the California experience was not the best choice. As with the experiences playing out in the public school systems nationwide, we are going to have significant mental, physical and economic damage to contend with over the next years to decades based on faulty assumptions and political/media hysteria.

For example, we are now seeing numerous studies pointing to increased abuse, mental despair, decreased healthcare access, stress, financial ruin and on and on. Even a recent study on myopia in China is showing us the negative effects of virtual learning on a child's visual development. (Wang et. al. 2021)

This is the segway into #4 and the need to be back in school.

4) Over the past year, many National and State Pediatricians have steadfastly pushed for in-person schooling for young children due to the inherent risks associated with a lack of quality education and disruptive home environments for the disadvantaged when forced to virtual learning environments. (Dorn E. 2020) In the beginning, the data was slanted towards in-person schooling, but it was not conclusive leaving the door open for the public school systems to keep learning mostly via the internet. In North Carolina, Governor Cooper and the State legislators prudently opted for a hybrid or all remote model to be chosen by each school district based on early data points in each local region. Unfortunately, children’s learning in the virtual model is lagging significantly and indicators of safety and wellness are declining rapidly for children confined to unhealthy home environments.

As a pediatrician, I have the privilege to meet with hundreds of parents a week to measure the pulse of the social educational experience and persistent home confinement. The current educational body is on life support by virtue of poor quality virtual experiences coupled with difficult family experiences in these trying times. These issues are compounded by homes with limited tech infrastructures. As a consequence, we are seeing significant scholastic struggles, increases in mental health struggles, weight gain, somatic complaints and abuse.

In person schooling is paramount to the success of our most marginalized school children. They have no luxury for tutors, coaches, stable home environments or high quality nourishment physically and mentally. We must weigh the measure of pandemic risk versus the downstream effects of virtual schooling. There are no easy decisions here.

Fast forward to January 2021 and we have much more data from which to make more targeted and educated decisions.

This month Dr. Zimmerman and colleagues, including my residency colleague Dr. Benjamin, published an article looking at school COVID transmission in the first 9 weeks of this fall in North Carolina. They found : "RESULTS: Over 9 weeks, 11 participating school districts had more than 90,000 students and staff attend school in-person; of these, there were 773 community-acquired SARS-CoV-2 infections documented by molecular testing. Through contact tracing, NC health department staff determined an additional 32 infections were acquired within schools. No instances of child-to- adult transmission of SARS-CoV-2 were reported within schools. CONCLUSIONS: In the first 9 weeks of in-person instruction in NC schools, we found extremely limited within-school secondary transmission of SARS-CoV-2, as determined by contact tracing." (Zimmerman et. al. 2021)(I have attached the study below for your reference)

This is the most declarative study to date and is completely affirming of the beliefs of the Pediatric Medical Community Nationally. Sweden released their data affirming this point. They had very low intra school spread. (Ludvigsson et. al. 2021) How much data do we need to see that the scales are now tipped toward in-person learning? COVID19 yet again is a lose-lose situation. We all can agree on this fact. However, are we still willing to let our children languish in the chair of online learning despite the safety data staring at us? (Avery et. al. 2020)

I know that these are always charged discussions. However, we are and should be focused on the child's health and vitality above all else where possible.

A recent statement by the American Academy of Pediatrics President, Dr. Lee Savio Beers, states: "Children absolutely need to return to in-school learning for their healthy development and well-being, and so safety in schools and in the community must be a priority,” “We know that some children are really suffering without the support of in-person classroom experiences or adequate technology at home. We need governments at the state and federal levels to prioritize funding the needed safety accommodations, such as improving ventilation systems and providing personal protective equipment for teachers and staff.” “No single action or plan will eliminate the risk of virus spread at a school, but we have seen how face masks, physical distancing and other measures when combined can significantly lessen the risks,”

Simply put, schools need to be open lest we further damage the economic and health vitality of children nationwide. In a very well thought out Op-Ed in Medpagetoday, Drs. Kogan and Prasad lay out a cogent opinion as to why we should do everything possible to keep schools open. (Kogan et. al. 2020) It has become ever more clear that school closure had marginal effect on reducing SARS2 pandemic levels while it most definitely has damaged the educational and health prosperity of this current generation of children nationwide. The data is flying in weekly about the negative effects of online learning in primary schools from poor education, to myopia, to children’s mental health declining rapidly and so much more.

There are many examples of effective in person learning in the country in both private and public school models.(Keung Hui 2020) We should be looking to these best practice models for the whole national school system. All of this is predicated on the volume of community viral activity and the financial support of the government. If an outbreak occurs in a school, then all of the protective measures should be taken and that school can close down for 2 weeks. Blanket virtual learning is not the answer as our children are losing ground faster than expected and safety is proven for in person activity.

We have known for decades that children are the epicenter of viral spread for influenza and other respiratory viral diseases leaving many to believe that school closure was a brilliant idea. By this time every year, we are normally inundated with influenza and RSV, yet, this has not occurred this year. The logical explanation is that we have slowed the spread of viral disease through mask wearing and social isolation. Closing schools will effectively stop much of the spread of these viral diseases. However, unlike influenza, SARS2 is not spreading well among the children. Young adults and teenagers are more effective at spreading disease making them a more select group to worry about, but even then, the vast majority of spread to date is adult to adult. Learning is the key to effective decision making in real time and we are not learning at the public school level where it relates to viral transmission and risk assessments. We are repeating the non scientific mantra that in person school closure is safer and better despite all of the evidence to the contrary.

As always, safety is the key to return to school full time as study after study has demonstrated when following the AAP plan. See the recent publication on January 5th.

As a Pediatrician, I chose to be on the front lines to help everyone regardless of race, color, creed or gender. I cannot, in good conscience, not point out the inequities occurring right now. We need our children, all children, your children educated and socially cared for. It is time to stop letting COVID win every battle.

The data is clear that in person learning is viable now with the standard safety precautions as laid out in the American Academy of Pediatrics recommendations page as well as the North Carolina Pediatric Society’s page. We are in difficult times, but as always we should look toward best practices being demonstrated in published studies.

American Academy of Pediatrics recommendations page:https://services.aap.org/en/pages/2019-novel-coronavirus-covid-19-infections/clinical-guidance/covid-19-planning-considerations-return-to-in-person-education-in-schools/
NCPeds Page: https://cdn.ymaws.com/www.ncpeds.org/resource/resmgr/news_/Back_to_School_Press_Stateme.pdf

5)Rerunning this one again for anyone that missed it last week. "It’s at least a reasonable, “parsimonious” explanation of what might have happened. This may be the great scientific meta-experiment of the 21st century. Could a world full of scientists do all kinds of reckless recombinant things with viral diseases for many years and successfully avoid a serious outbreak? The hypothesis was that, yes, it was doable. The risk was worth taking. There would be no pandemic. I hope the vaccine works." (Baker N. 2020)

This article is one of the more shocking of the last 12 months. Mr. Baker writes in the New York Times Magazine about the possible origins of SARS2/COVID19. I will readily admit, that after studying medicine for 29 years, the thought that SARS2 was a natural event seemed dubious. While I am not a virologist, critical thinking and all of my learning have forced me to look closely at these odd events that led to the pandemic. This article is long and thorough and goes over large gaps in information that coalesce into a more plausible story than that which has been propagated since February. It is absolutely worth reading in its entirety. Anything less than a full read will leave you with a partial picture.

Regardless of where you fall on the origins story, I fully believe that we should investigate the origins story at an international level. Millions have died and answers are necessary.

6) New strains of SARS2 - Recent data has shown that there are new circulating strains of the SARS2 virus in California, Colorado and other states. That means it is now effectively going to be everywhere by spring. It still appears that the newer versions have slight genetic modifications to the spike protein on the viral surface that is increasing the infectivity. The good news is that there has not been a change in the morbidity or mortality related to the mutation. We will be watching this closely. (Kupferschmidt K. 2020)

This new mutation has popped up in three different locations globally, the United Kingdom, Brazil and South Africa. This only occurs when the mutation offers a significant advantage to the microbe for survival. From The Atlantic, "The role of each individual mutation is still unclear, but a particular mutation in the spike protein called N501Y is noteworthy because all three variants have it. The spike protein is how the coronavirus enters cells, and N501Y is in an especially important region called the receptor-binding domain, which latches on to the cell. An N501Y mutation may make the spike protein stickier, allowing it to bind to and enter cells more readily. Such a virus could become more transmissible. On the plus side, however, the mutation doesn’t seem to affect immunity from vaccines."(Zhang S. 2021)

There are some other mutations that are conferring other benefits to the virus including potentially evading our antibodies making reinfection more possible. The virus will continue to mutate to its advantage while our immune system works hard to counteract all changes. It is an arms race. Hopefully, the vaccines will tip the scales in our favor. Read The Atlantic article as it is a good one.

We will be very closely watching the vaccine effectiveness against any and all SARS2 mutations.

7) COVID prevention strategies are still putting off influenza and viral upper respiratory season. (Jones et. al. 2020) As of this weekend, we have seen one influenza case in children this year. According to the CDC there is still an unbelievably low volume for this time of the calendar year. (CDC flu stats)

8) In a recent publication in the Journal Gut, Dr. Yeoh and colleagues analyzed the microbiome of COVID19 patients and noted abnormal microbial makeups were associated with worse disease. They state, "Gut microbiome composition was significantly altered in patients with COVID-19 compared with non-COVID-19 individuals irrespective of whether patients had received medication. Several gut commensals with known immunomodulatory potential such as Faecalibacterium prausnitzii, Eubacterium rectale and bifidobacteria were underrepresented in patients and remained low in samples collected up to 30 days after disease resolution. Moreover, this perturbed composition exhibited stratification with disease severity concordant with elevated concentrations of inflammatory cytokines and blood markers such as C reactive protein, lactate dehydrogenase, aspartate aminotransferase and gamma-glutamyl transferase." What the authors are saying directly relates to the entire microbiome discussion. If we choose the wrong lifestyle choices chronically, we will end up with a dysfunctional microbiome that increases the risk of severe COVID disease.

There is a direct link between our lifestyle choices, microbiome composition, disease morbidity and finally COVID death risk. 95% of deaths are defined by this paradigm.

9) Repeat based on importance - Loss of smell is more common with mild COVID than severe disease. At 6 months post infection, 95% of individuals can smell again. (Lechien et. al. 2020) That means that 5% of post COVID infected humans are anosmic or cannot smell and therefore cannot effectively taste. This is a hot mess. Run the earlier numbers for known sick persons at 5% of 21,000,000 - just over 1 million people.

Omega 3 fatty acids could be beneficial in hastening the return of neurological function in the olfactory region as these fats increase the production of resolvins, protectins and defensins in the brain known to be beneficial in brain healing from concussion/head trauma. There are no studies specifically related to COVID and loss of smell to date to my knowledge.

6 months after recovering from acute COVID hospitalization, 63% of affected individuals still had symptoms. The authors state, "Fatigue or muscle weakness (63%, 1038 of 1655) and sleep difficulties (26%, 437 of 1655) were the most common symptoms. Anxiety or depression was reported among 23% (367 of 1617) of patients." (Huang et. al. 2021)

The long hauler data, the death data, the tissue damaged survivors and complications data are enough to push me toward a vaccine if I was ever hesitant.

Folks - this virus is special. Regardless of the origins story, it is here and present in a nasty way. The death data is and has improved over time and that is good. The harder part now may start to be what is left behind for the survivors with severe disease or those milder cases that cannot smell anymore.

Again, I am presenting the data and my opinions based on it. We all must choose our paths.

10) Vaccination in Israel has now passed one fourth of the population and the results are showing a decrease in infection rate. This is great news. Here is to hoping we get there sooner than later. (Schwartz F. 2021)

11) Twin studies offer a rare glimpse at identical genes with disparate outcomes pointing a light at the epigenome and environmental influences or viral load at the disease outset. (Goel et. al. 202)

12) Having a history of COVID prior infection conferred 83% protection against a future infection according to a large study called SIREN. The protection lasts at least 5 months. (Hall et. al. 2021)

13) Mask wearing is the least that we can do until things slow down and vaccinations are in full effect. They work folks. The absolute reduction in transmission in our clinic of SARS2 and also influenza community wide is a testament to the interventions role in control. In a study by Rader and colleagues, they found a significant benefit in infection reduction through mask wearing. (Rader et. al. 2021) While it is a pain to do, it is useful and should be universal at this time. (Howard et. al. 2021)

14) Recent data supports the early American College of Cardiology advice that for athletes with mild or asymptomatic disease, cardiovascular workup is unnecessary. With moderate febrile disease or worse, a full cardiac workup is warranted. (Hwang et. al. 2021)

Dr. M

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