Volume 11, Letter 21 Coronavirus Update 35
May 10th, 2021
The United States is on a great trajectory overall, while globally things are dramatically turning to trouble.
The United States is now past 46% of its over 18 year old population having been vaccinated with at least one dose, making the vaccinated and or previously infected number heading towards a herd immunity location in the not too distant future. Fingers crossed.
113 million Americans are fully vaccinated with most being higher risk. 151 million have at least one dose. This reality can now help us restore a normalcy to life sooner than later as the vaccine is drastically reducing the risk of death and hospitalization.
North Carolina now has 75% of individuals over 65 years of age fully vaccinated.
The vaccines continue to be effective against the variants.
As it stands today, the United States has had 32.7 million cases and almost 581,000 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.
Mathematically, you now have a 99.9998% chance of survival once vaccinated.
1) COVID19 is primarily a vascular disease and not a pulmonary disease unifying previously disparate understandings of the disease's pathogenesis. In a fascinating study from Circulation Research, we see evidence that the SARS2 spike protein directly affects the endothelial lining of blood vessels in the body independent of live SARS2 viral RNA. (Lei et. al. 2021)
The science: the SARS2 virus uses the angiotensin converting enzyme 2 receptor, ACE2r, to bind to the lung tissue. In this study, the authors showed that the binding of the spike protein to the ACE2r triggered a decrease in the enzyme ACE2 which in turn reduced the function of the mitochondria, cell powerhouse, of the endothelial cells of the blood vessel. The loss of the mitochondrial function, ATP energy production, leads to cellular damage and then local dysfunction until enough tissue is damaged leading to the symptoms that we see of in COVID19 vascular disease.
This research is profound and opens up a host of questions. If the spike protein alone can cause blood vessel dysfunction independent of SARS2 viral viability via these pathological pathways, can the vaccine which induces spike protein production do this on a micro scale? So far, this seems unlikely based on the post vaccination surveillance to date. However, it is worthy of analysis and understanding. This in now way would change my desire to vaccinate as the vaccine risk is unlikely and theoretical while disease risk is known.
2) Full vaccination induced herd immunity is unlikely to come any time soon, but we are in really good shape. The US vaccination experiment has been fantastic to date but is unlikely to get us to herd immunity alone as the current threshold that we need to hit via vaccination is high compared to the volume of Americans willing to be vaccinated. Thus, we will likely continue to have small pods of disease in areas where people are not vaccinated and exposed to disease without PPE. However, these pods of disease should be smaller and less frequent as there are less unvaccinated and not previously infected hosts available to get infected and transmit the virus onward. No longer are we going to be in a situation where 1 super spreader will infect the majority of a room unless it is an unvaccinated group.
This will be our new norm pending either more vaccination or a viral variant that changes the current reality. We need to get back to normal life. The pandemic has highly likely turned the corner on massive risk or even major risk. See next.
To listen to a high level podcast on the COVID19 vaccines, safety and other related topics, listen to Dr. Peter Attia's interview with Dr. Paul Offit at this link. They do an excellent job discussing the current state of vaccine usage, development and herd immunity possibility. There are controversial discussions later in the podcast regarding origins and vaccinating children that will be hotly debated for some time.
3) "Ending the COVID-19 pandemic will require long-lived immunity to SARS-CoV-2. We evaluated 254 COVID-19 patients longitudinally from early infection and for eight months thereafter and found a predominant broad-based immune memory response. SARS-CoV-2 spike binding and neutralizing antibodies exhibited a bi-phasic decay with an extended half-life of >200 days suggesting the generation of longer-lived plasma cells. In addition, there was a sustained IgG+ memory B cell response, which bodes well for a rapid antibody response upon virus re-exposure. Polyfunctional virus-specific CD4+ and CD8+ T cells were also generated and maintained with an estimated half-life of 200 days. Interestingly, the CD4+ T cell response equally targeted several SARS-CoV-2 proteins, whereas the CD8+ T cell response preferentially targeted the nucleoprotein, highlighting the importance of including the nucleoprotein as a potential vaccine antigen. Taken together, these results suggest that broad and effective immunity may persist long-term in recovered COVID-19 patients." (Cohen et. al. 2021)
This piles on top of many other studies in the last 12 months showing us that many individuals will have quality adaptive immunity post COVID19 illness. This study shows a greater than 200 day antibody response and counting. Knowing this data and others to date coupled to the active vaccination effort may allow me to retract my previous statement regarding herd immunity. That would be lovely.
The possibility that active vaccination numbers coupled to previously infected individuals could get us to a place where only rare cases would occur would be great and I am hopeful. Either way, as I have stated in previous newsletters, we are definitely on track for much less disease risk from COVID19 as a society.
4) Vaccine breakthroughs are very rare and may be a window into new variants if and when they show up in a more problematic way. According to the CDC, out of 95 million vaccinated Americans, there were 112 deaths and 596 hospitalizations of the breakthrough type despite all known variants of SASR2. That is mathematically a 99.9998% chance of survival once vaccinated. If that is not a plug to be vaccinated, I am not sure what is. (CDC Data) 577,000 Americans that have succumbed to the disease are sad reminders of the SARS2 virulence.
All breakthroughs should be checked for new variants to find and stamp out a risky variant alteration if and when it occurs.
5) Let us hope that we never try to close schools again for a prolonged period of time for the remainder of this century. The cost for children's physical and mental health was too high. In a study from JAMANetwork we see negative mental health data post school closure across the board. Loneliness increased 28%, anger 20%, stress 13%, anxiety and depression 11%. (Kluger J. 2021)(Raviv et. al. 2021) These mental health challenge increases are placed on top of the already high burden of societal children's health.
This and many other reports from the pandemic are a full force indication that teachers and schools are paramount to a child's nurturing and health especially when the home environment is at risk. The value of constant exposure to quality adult led education can not be overstated.
This pandemic has been a learning experience that historians and policy makers must use to make better plans for future events.
6) As we get closer and closer to the time when children will receive the indication for COVID vaccination, we will see many differing opinions as to do or not to do. Here is a caution article in the British Medical Journal noting that the data is being skewed to push a stronger long hauler narrative in children than might be occurring if the data is looked at more clearly against a control group. (Bhopal et. al. 2021) The truth is that currently we have limited to no accurate data on the Long Hauler phenomena in children although we know that it is happening in a small number of cases. These rare cases can be truly debilitating making the question of vaccination for children worth discussing despite the adult risk reduction through vaccination.
It is clear that in very rare cases, COVID19 can be a train wreck for a child.
7) A very thoughtful article on mass testing in schools is worth a read. I agree with the principles as laid out in the article. (Hoeg et. al. 2021)To test randomly for asymptomatic spreaders in a low risk environment where the teachers are vaccinated makes little sense. To test symptomatic individuals makes sense in order to promote quarantining unvaccinated adults and other exposures. To test asymptomatic people will likely find false positive cases further subjecting children to lost school time and more health consequences.
8) Here we go again. State COVID rules will be vastly different moving forward. Florida's governor has just rescinded all COVID restrictive rules and will show a diametrically opposed view of life to California and New York. (NPR 2021) Citing ample vaccine availability and no issues meeting the needs of those requesting vaccination, the state will return to pre pandemic life by July 1st. We will keep a close eye on the outcomes of the disparate economic/social governmental choices.
States are the best incubators of best policy and choice moving forward.
9) "Higher level of habitual physical activity is associated with a 31% risk reduction of community-acquired infectious disease and 37% risk reduction of infectious disease mortality. Physical activity interventions resulted in increased CD4 cell counts and salivary immunoglobulin IgA concentration and decreased neutrophil counts compared to controls. Antibody concentration after vaccination is higher with an adjunct physical activity programme. " (Chastin et. al. 2021)
This study adds to many data sets giving us insight into activities beneficial effects on immune activity and function. Walking a few miles a day is ideal. Or better yet, develop a group of F3 style friends that will hold you accountable and push you to be a better physical version of self every day. Moderate daily exercise = longer life. This is undisputed unless you get hit by a bus while walking and texting!
10) In an opinion piece by Joseph Allen from Harvard University School of Public health, we see a nice discussion on masking and the return to normalcy by July 4th of this year once it is clear that every American at risk has had the opportunity to vaccinate and has chosen one way or the other.
In my opinion, we cannot hold the United States hostage to the pandemic any further now that a remarkably effective therapy is available and offered to all. There are those like Dr. Paul Offit who has stated that all Americans should be mandated/forced to receive a COVID19 vaccine for the collective prevention of COVID disease in the society at large. I fall short of this mandate as I think that while the vaccine is safe, we still need more data over years for complete knowledge of risk making a mandate difficult to propose.
I willingly took my doses knowing the risk and reward. The scales are heavily tipped toward my reward via vaccination.
These will always be difficult conversations and decisions, yet, I would rather have them then live in a world without discourse and compromise. That is a scary world view in my mind. I teach my children and patients that thought and discourse are the route to success as medicine has taught me time and again.