April 12th, 2021
What will we need post COVID to be ready for the tide of mental and physical health issues that are sure to wash ashore?
The simple answer is personal accountability. This is the only piece of the puzzle that is within our control and completely modifiable. Whether you have cardiovascular disease, diabetes, hypertension, obesity, fatigue, etc...., you have the ability to follow a simple lifestyle roadmap to healing that will alter your outcome for the positive. See Section II.
Quick hits
1) Will we need to get boosted soon for COVID19 after being effectively vaccinated? In my opinion, no. It is very clear from the literature that we are developing very robust T and B cell responses post mRNA COVID vaccination. (Ellebedy et. al. 2021) It is also clear now that the immunity post vaccination is completely stopping the death and hospitalization nightmares of 2020. (Business Wire 2021) How long does the immunity last is still anyone's guess, however, the reality is likely somewhere between a long time and many years. I do not suspect that we will need yearly boosters. Every month that passes is another net positive towards long lasting immunity.
The only vaccine that needs a yearly booster is the influenza vaccine. And this is purely because the influenza virus has a rapid ability to shift and drift it's genetic code via an RNA polymerase enzyme thwarting a previous vaccine. (CDC site)(Bouvier et. al. 2008) Coronaviruses have an RNA polymerase as well, however, the speed of variant development is not rapid making the current vaccine strategy quite likely to last for years if not decades. (Denison et. al. 2011)
2) Hospitalizations continue to drop despite an increase in cases in some regions of the United States. This again shows the effectiveness of the vaccinations at reducing the severity of disease nationwide despite the variants. This reduction in hospitalizations will undoubtedly lead to less deaths as one follows the other. (CDC Tracker Site)
Again, we see strong data supporting a continued normalization of lifestyle activities when you have completed the 2 shot series. It is very clear that cases are less concerning if they do not induce hospitalization and or death. At the current vaccination rates, we are on track for a rapid conclusion of the main struggles of the pandemic barring a highly unlikely mutation problem.
3) 2020 death etiologies were noted to be highest for cardiac disease at 690,000, next was cancer at 598,000 and third was COVID-19 with 345,000 deaths. Last year, the age-stratified death rate went up 16%.(CDC MMWR) These numbers are of little value yet, as we need comparison numbers over the next few years to ascertain the actual number of advanced deaths by age. It is likely an age stratified early expiration of significantly at risk individuals as opposed to 10 to 20 year advanced death. This understanding in no way minimizes the sadness of any single death, so much as it shines a light on what we can all do to reduce our collective risk over time for all disease.
4) "Individuals discharged from hospital after covid-19 had increased rates of multiorgan dysfunction compared with the expected risk in the general population. The increase in risk was not confined to the elderly and was not uniform across ethnicities. The diagnosis, treatment, and prevention of post-covid syndrome requires integrated rather than organ or disease specific approaches, and urgent research is needed to establish the risk factors." (Ayoubkhani et. al. 2021)
This study clearly delineates the post hospital time period as significantly risky for death. The hospitalized person suffers significant inflammation resulting in organ damage that if not properly treated post discharge can lead to death. If a family member has recently been discharged, stay on top of their follow up visits and medication management to reduce the risk of death.
Again, this post hospitalization time is critical from a nutrition, rest, stress and movement perspective. Follow the basic principles of an anti inflammatory diet coupled to targeted anti inflammatory supplements guided by your provider.
5) COVID19 affects the brain! From JAMAPsychiatry, "Some patients present with anosmia, cognitive and attention deficits (ie, brain fog), new-onset anxiety, depression, psychosis, seizures, and even suicidal behavior. These present before, during, and after respiratory symptoms and are unrelated to respiratory insufficiency, suggesting independent brain damage. Follow-ups conducted in Germany and the United Kingdom found post–COVID-19 NPs in 20% to 70% of patients, even in young adults, and lasting months after respiratory symptoms resolved, suggesting brain involvement persists." (Boldrini et. al. 2021)
This article is deep and fantastic. It is worth your time if you wish to understand the underpinnings of post COVID brain issues from an immune perspective. Post COVID brain issues are very similar to post traumatic brain damage. Immunologically activated microglial cells mediate inflammation based damage to many brain cell types in an effort to clean up the damage. The more the intra brain inflammation occurs, the more tissue destruction follows in lock step.
Continuing this theme, the journal Lancet Psychiatry published data on neuropsychiatric, NP, conditions post Covid this month. "Among 236,379 patients diagnosed with COVID-19, the estimated incidence of a neurological or psychiatric diagnosis in the following 6 months was 33%, with 12% receiving their first such diagnosis. For patients who had been admitted to an ITU, the estimated incidence of a diagnosis was 46% and for a first diagnosis was 26%. (Taquet et. al. 2021) The researchers compared three groups on patients over the age of 10 years: COVID19, influenza and other respiratory viruses. They looked at these 14 conditions as a negative NP outcome: intracranial haemorrhage; ischaemic stroke; parkinsonism; Guillain-Barré syndrome; nerve, nerve root, and plexus disorders; myoneural junction and muscle disease; encephalitis; dementia; psychotic, mood, and anxiety disorders (grouped and separately); substance use disorder; and insomnia.
The risks increased with the severity of disease.
6) "In general, factors such as duration and frequency of personal contact, lack of personal protective equipment, and occasional indoor gathering during a largely outdoor experience were associated with outdoor reports of infection." (Bulfone et. al. 2021) There are still areas where clusters of infection can spike and they remain primarily in adult activity where social distancing and PPE are not in effect for unvaccinated individuals. The fallacy of safety in an outdoor experience is proven during outdoor events that invariably find individuals clustering inside for air conditioning, restrooms, conversation or food. These situations are best handled with avoidance of risk by maintaining social distances of at minimum 3 feet, wearing your mask and following basic lifestyle choices that maintain robust immune activity. The new variants are spreading faster with a greater R0 than the original strain of SARS2. Choose wisely if you have not been vaccinated.
7) Patients that recovered from COVID19 hospitalization had altered immunology post recovery. In the journal Cell, Shuwa and colleagues discussed their findings: "We report that the alterations in B cell subsets observed in acute COVID-19 patients were largely recovered in convalescent patients. In contrast, T cells from convalescent patients displayed continued alterations with persistence of a cytotoxic programme evident in CD8+ T cells as well as elevated production of type-1 cytokines and IL-17. Interestingly, B cells from patients with acute COVID-19 displayed an IL-6/IL-10 cytokine imbalance in response to toll-like receptor activation, skewed towards a pro-inflammatory phenotype. Whereas the frequency of IL-6+ B cells was restored in convalescent patients irrespective of clinical outcome, recovery of IL-10+ B cells was associated with resolution of lung pathology." (Shuwa et. al. 2021)
The clinical relevance of the persistence of T cell pro inflammatory activation post recovery remains to be seen, however, it is not normal and appears to be associated with worse pulmonary outcomes and may be a part of the long COVID conundrum. Certain individuals with COVID appear to be susceptible to worse disease early on leading to hospitalization/death and then a further subset remain abnormally immunologically polarized towards inflammation and worse chronicity of illness.
This is the kind of information that would be amazingly useful if we had a priori knowledge of a genetic risk for an individual to have a negative immune polarity shift long term. I.e. gene testing that could tell us in advance who is at greatest risk. We know based on the epidemiology that individuals with obesity, diabetes, hypertension and cardiovascular disease have higher risks based on their inflammatory polarity, however, honing this data further to the highest risk would be very useful for targeted therapy and vaccinations.
8) More great news from Israel! "Mass vaccination has the potential to curb the current COVID-19 pandemic by protecting vaccinees from the disease and possibly lowering the chance of transmission to unvaccinated individuals. The high effectiveness of the widely-administered BNT162b vaccine in preventing not only the disease but also infection suggests a potential for a population-level effect, critical for disease eradication. However, this putative effect is difficult to observe, especially in light of highly fluctuating spatio-temporal epidemic dynamics. Here, analyzing vaccination records and test results collected during a rapid vaccine rollout for a large population from 223 geographically defined communities, we find that the rates of vaccination in each community are highly correlated with a later decline in infections among a cohort of under 16 years old which are unvaccinated. These results provide observational evidence that vaccination not only protects individual vaccinees but also provides cross-protection to unvaccinated individuals in the community." (Milman et. al. 2021)
This is hugely relevant to all of the discussions surrounding pandemic resolution. The fact that cross protection is occurring in non vaccinated individuals in the households of the vaccinated is so important as this slows the rate of disease transmission and ultimately mutation. Let us think about the school setting. Most in school cases came from adult teachers outside the school setting. Now that the teaching adults are vaccinated the risk of in school transmission is relieved. The end result will hopefully be getting children back in school without restrictive masks and other impediments to the normalcy of life. It is likely only a matter of months now.
9) It is time to have the conversation about kids wearing masks while engaging in sport. In an Irish study, they found 1 per 1000 COVID cases could be traced to an outdoor activity. (McGreevy R. 2021) This mirrors the data from other outdoor transmission studies. The issue with transmission remains steadfastly with 20 to 50 year old unvaccinated individuals engaging in activities in crowded indoor environments with poor ventilation over TIME.
It is the opinion of this writer that school sport masking in outdoor environments makes less sense now following the data trail.
Dr. M
Ellebedy Nature Portfolio Sciences
Businesswire Pfizer
Kim Viral Immunology
Bouvier Vaccine
Denison RNA Biology
Ayoubkhani BMJ
Boldrini JAMAPsychiatry
Taquet Lancet Psychiatry
Bulfone J of Infectious Diseases
Shuwa Cell
Milman MedRxIV
McGreevy The Irish Times
