March 15th, 2021
COVID newsletter number 1 was this time last year. So much has transpired in the last 12 months. So many thoughts. Silver linings. Frustrating negatives. Children left behind. Too many deaths.
Alas, this is exactly what life is. Events in time. We must view life from the present and not dwell on the past while we earnestly prepare for the future learning from the past.
Latest numbers google/CDC show that cases peaked in early January and continue to aggressively trend down.
The United States is now likely past 40% of its population having been vaccinated or previously infected. Couple this with warming weather patterns, effective social distancing and we are in better shape every day.
We are currently vaccinating 2 million people per day. Just under 20 million Americans are fully vaccinated with an additional percentage one dose in. So far the vaccines are working against the variants.
As it stands today, the United States has had 29 million cases and almost 530,000 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 thislink.
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.
Coronavirus Update 31
According to the CDC: fully vaccinated people can:
• Visit with other fully vaccinated people indoors without wearing masks or physical distancing
• Visit with unvaccinated people from a single household who are at low risk for severe COVID-19 disease indoors without wearing masks or physical distancing
• Refrain from quarantine and testing following a known exposure if asymptomatic
The end is in sight. Vaccines are working and restrictions are being lifted for the fully vaccinated. This was a great move by the CDC as the data bears out the extremely low risk of any problems after vaccination has occurred.
The roaring 20's are on the way as the pent up demand for a normal life is bubbling out of the closed environments.
On that note, a new study by Dr. Morrow from Emory University shows that by October of 2020, 1 in 8 Americans had antibodies to COVID. That is 39 million infected individuals BEFORE the major surge in the winter which added 2-3 X that number. Folks, add this data to the current vaccine regimen and we are likely done with major COVID issues. There is no guarantee and I am hypothesizing, but it truly feels like the worst is behind us.
Quick hits
1) Early data from the worldwide vaccine surveillance is coming in with resounding positive notes. Israel has the most robust data, but the rest of the industrialized world is following suit. The plummeting death and hospitalization rates despite new mutant strains being in existence is early proof positive that the vaccines and those having a previous infection are getting enough immune benefit to change the natural course of this disease in the immunologically SARS2 naive human.
The newer strains are more infectious. True. However, this may be irrelevant moving forward if, and only if, the new strains do not gain a novel killing advantage and the current reality maintains that some a priori viral exposure gives our immune systems enough of a head start to thwart a viral load gain.
2) More data that those that were previously infected have only a 0.3% chance of reinfected with SARS2. (Harvey et. al. 2021) This continues to add to the great news moving forward.
3) Florida and California had similar rates of COVID disease per capita despite vastly different approaches to lockdowns, masking etc. Similarly, Belgium, France, England and Sweden all had the disparate approaches and outcomes with no clear evidence that restrictive measures were more beneficial. People have tried to answer the why with little to nothing to show for their work to date. (Johns Hopkins Data)
The reality is that in a pandemic the only real control could occur by a strict lockdown of the index cases at the outset. Once the containment was broken there was no way to stop it. Lockdowns were ineffective unless you lived on an Island and could stop boats and planes from landing as was the case with New Zealand and Hawaii. Any contiguous nationstate had an impossible task set before them when the virus had spread in the early phases. Density of living, excessive exposure time to a sick individual, poor host health and poor hygiene were the clear risk factors to viral spread as they have always been.
When this pandemic finally comes to a reasonable conclusion, the main focus must be on public health education regarding the etiologies of death and disease - food, movement, stress, chemical exposure and the governments complicit subsidy for the processed food economy.
4) North Carolina School scores are in and it is as bad as expected. From the News and Observer we see the following:
The majority of students failed the Math 1, Math 3 and biology exams.
▪ In Math 1, 66.4% of test-takers were not proficient. It was 48.2% during the fall 2019-20 semester.
▪ In Math 3, 54.9% of students were not proficient on the test. It was 44.5% the prior fall semester.
▪ In biology, 54.5% of students were not proficient. It was 42.1% the prior fall.
▪ Only in English 2 was there any improvement. This year, 41..4% of students were not proficient compared to 42% the prior fall. (News and Observer Article)
This reality was a foregone conclusion. Virtual learning was never going to work for the children on the margins and did not even work for the vast majority as we are now seeing. There is only one conclusion that can be drawn. In person education is beyond vital to the proper functioning of a modern society. We are a long way away from effective home based educational endeavors for most of America.
Teachers are so important to the vitality of the child's mind. This virtual experiment thrust upon the United States has slammed the door shut on leaving the hallowed halls of in person schooling.
5) If you had the SARS2 virus in the past, you have a 2 fold improved antibody response after one dose of an mRNA vaccine. (Ciccone et. al. 2021) As expected immunologically, if you have seen this virus before, the system is primed to take strong action more rapidly. More good news for a large swath of America.
6) Long term symptoms remain a major concern for survivors. In a new study from JAMA, we see acute and 9 month follow up data. In this cohort study, approximately 30% of post COVID infected individuals reported prolonged symptoms at 3 weeks post illness. The authors also looked at mostly outpatients with mild COVID disease making it a first of its kind study. Fatigue was the most common symptom in 14% at 9 months. Loss of smell persisted in 14% as well. (Logue et. al. 2021)
Again we see daunting prospects for future mental and physical health in a subset of post COVID patients. The number remains significant. To date their are now two major studies on long term symptoms with this study having the highest number at 14%. That is a large number. Between 5 and 14 of every 100 recovered individuals have fatigue and loss of smell at 9 months. Add in the autoimmune diseases that are turning on and we have a public health emergency looming in the wake of the acute pandemic.
This data set again leads me to recommend vaccination against SARS2 for all individuals eligible this year. Most of my colleagues have had both doses of either the Pfizer or Moderna vaccine with no negative consequences to date. That is great news and hopefully is useful to you.
More on the long haulers.
7) "Reports of long-lasting coronavirus disease 2019 (COVID-19) symptoms, the so-called ‘long COVID’, are rising but little is known about prevalence, risk factors or whether it is possible to predict a protracted course early in the disease. We analyzed data from 4,182 incident cases of COVID-19 in which individuals self-reported their symptoms prospectively in the COVID Symptom Study. A total of 558 (13.3%) participants reported symptoms lasting ≥28 days, 189 (4.5%) for ≥8 weeks and 95 (2.3%) for ≥12 weeks. Long COVID was characterized by symptoms of fatigue, headache, dyspnea and anosmia and was more likely with increasing age and body mass index and female sex. Experiencing more than five symptoms during the first week of illness was associated with long COVID. A simple model to distinguish between short COVID and long COVID at 7 days showed an area under the curve of the receiver operating characteristic curve of 76%, with replication in an independent sample of 2,472 individuals who were positive for severe acute respiratory syndrome coronavirus 2. This model could be used to identify individuals at risk of long COVID for trials of prevention or treatment and to plan education and rehabilitation services." (Sudre et. al. 2021)
To me, these long COVID data sets are pointing to an inability to handle the virus early on in the disease process coupled to significant inflammation and tissue damage leading to the long hauler syndrome. I believe that there will be a significant autoimmune component for these individuals. The precursor risks for a negative outcome are all inflammatory in nature including diabetes, cardiovascular disease and obesity. Thinking about the recent insulin resistance articles, we can get a real long term picture of the why these individuals are in a suffering state. Whether you have one of these diseases, COVID long hauler, autoimmunity or cancer, the upstream risk is all the same.
8) Despite many people fearing mask wearing being a net negative on respiratory function in very young infants and children, a recent study from Italy says that this is not occurring. They looked at 47 children for 30 minutes of continuous mask wearing. No changes in oxygen delivery to the tissues was note by pulse oximetry, respiratory rate or heart rate. (Lubrano et. al. 2021) While this data may seem useful, I question the validity of its use and purpose. First, 30 minutes is an insignificant amount of time in a school environment. The study should have looked at a minimum of 3 hours to reasonably equate to a school half day. Second, why are we even looking at this age group in the first place. They as a group, under 5 years of age, are not a part of the pandemic conflagration by illness or spread to others. If you read this headline in the popular press, I caution you to interpret the data with eyes wide open.
9) The United Kingdom has just published excellent data on hospitalization and death reductions post Pfizer and Astra Zeneca vaccines during the early 2021 period. During the period of time that accounted for the new circulating UK variant, death rates plummeted for the elderly. (Bernal et. al. 2021) Couple this data with the Israeli numbers and we are looking at a lovely picture that will significantly support a relative return to normalcy in months. (assuming no new variant changes)
The other fascinoma emerging in my mind is the relative ability to rapidly iterate the mRNA vaccine to a new SARS2 variant with extremely low known risk of side effect for a recipient. If the vaccine tech remains identical minus a slight change in the delivered viral mRNA segment, we will not have to wait for months to test it for safety. The production line could hum immediately following genomic sequencing and then distribution could target hot spots preventing mass spread. This ability could be a real game changer and another COVID silver lining for the future. Pandemics of the next generation may never again look like this. What an amazing thought!
10) Non pharmacological interventions, mask wearing, distancing and hand washing, DO help to reduce viral exposure and more importantly the viral load acquired if one is exposed. (Spinelli et. al. 2021) I cannot say it loudly enough. Our experience in pediatric clinic is profound. Viral upper respiratory diseases are flat lined this year. We are still at #3 influenza cases this year. For anyone that still harbors the belief that this is all garbage, please come and witness the truth from our eyes. This truth may be close to one of the most amazing experiences of my career.
11) Repeat - In an excellent report called the Rise of the Variants by Otello Stampacchia, we see a cogent analysis of the variant dilemma. I encourage everyone to read it. Here is the link.
12) More in school transmission data. This time from Georgia. (Gold et. al. 2021) When proper social distancing and mitigation measures are followed, transmission is negligible in school. Thus, the opposite is also true. When adult teachers shun mitigation measures or children are not expected to follow basic precautions, disease will spread. However, this spread in school is still minimal. Risk really occurs outside of school during daily activities by adults in the 20 to 50 year old age range who are non compliant with the guidance. Teenagers are also involved in small clustering events as has occurred in local private schools. However, these schools have done an excellent job and remained open all year keeping case spread to a minimum once identified. Kudos to them. A lesson for all to learn from.
13) A first of its kind T cell test will allow the medical community to more accurately diagnose who has been ill with SARS2 in the past. Whereas antibody testing is very flawed based on waning and non existent responses by some previously ill individuals, the T cell test is likely to become the gold standard for verifying previous illness. ( STAT article 2021)
14) It is highly likely that many children under 12 years of age have been infected and are now partially immune or fully immune. Most children have had little to no identifiable symptoms making diagnosis difficult until testing PCR became prevalent. Even then the PCR test is not great in the younglings as they often kill the virus quickly never testing positive.. It would be lovely to have the above T cell SARS2 test to get a true reading on a child's immunity. This would also help with the debate over vaccinating children in the future. Dr. Fauci is positing that Q1 of 2022 will be the likely vaccination time frame for children. This is going to be a tough sell for many parents based on the knowledge that this virus really is not affecting the children and they already may have immunity of some type. Furthermore, if the at risk population is fully vaccinated, what will the pressing need be for? Couple this fact with the fact that death and hospitalization post COVID vaccination is almost non existent, and the sell gets trickier. As always, the data will be presented over the coming year before any decisions need to be made.
15) The UK variant is associated with increased death risk. "The mortality hazard ratio associated with infection with VOC-202012/1 compared with infection with previously circulating variants was 1.64 (95% confidence interval 1.32 to 2.04) in patients who tested positive for covid-19 in the community. In this comparatively low risk group, this represents an increase in deaths from 2.5 to 4.1 per 1000 detected cases." (Challen et. al. 2021) The increased death risk is not occurring in the vaccinated groups based on neutralizing data and the Israeli experience which is the true news and takeaway. (Liu et. al. 2021)
16) 3 feet versus 6 feet of social distancing in schools = no difference. (Van den Berg et. al. 2021) This again is likely related to the fact that children are not the spread risk. Adults may be a much greater spread risk when they spend time within the 6 foot range.
17) Children's death risk from COVID still tiny. (Bhopal et. al. 2021)
18) COVID vaccine tech is already having spillover effects. The effective mRNA tech used by Moderna and Pfizer are being repurposed to fight malaria. Early reports show that there is a patent in the works for a new vaccine to fight malaria. This would be amazing news for the countries that straddle the equator. Over 400,000 humans lost their lives to malaria in 2019.
A silver lining to the pandemic nightmare will be future lives saved by the aggressive approach of Operation Warpspeed. (Ravisetti et. al. 2021)
19) The mRNA technology is going to revolutionize the future of pandemics and infectious disease. The mRNA vaccines will be game changers based on their ability to be rapidly changed to match the genetic code of the offending virus. Now we have news that there is a new medicine based on this technology that blocks the replication of the virus when it enters the lungs. Early work has been completed in rats showing great effectiveness. The inhaled medicine has degraded and reduced the influenza and SARS2 viral particles in the lungs. If a new iteration of the virus occurs, the new genetic variation can be plugged into the mRNA medicine for efficacy. (Blanchard et. al. 2021)
20) More conclusive evidence that blood grouping makes a difference in COVID risk. Wu and colleagues have shown that the SARS2 spike protein has a preference for the a antigen of blood group A. (Wu et. al. 2021)
21) Long term immunity pattern found in the germinal centers of the draining lymph nodes post SARS2 vaccination. (Ellebedy et. al. 2021) How long this immunity lasts is the million dollar question, but this is great news.
22) A good article written by Dr. Murray entitled, The Potential Future of the COVID-19 Pandemic
Will SARS-CoV-2 Become a Recurrent Seasonal Infection? discusses the possible realities of how this virus will play out over time in our midst. (Murray et. al. 2021)
Dr. M
Morrow Medical Xpress
Harvey JAMAInternal Medicine
Ciccone MedRxIV
Logue JAMA Network
Sudre Nature Medicine
Lubrano JAMANetwork
Bernal MedRxIV
Spinelli Lancet Infectious Diseases
Stampacchia Report
Gold CDC MMWR
Palmer STAT
Challen BMJ
Liu NEJM
Van den Berg Clinical Infectious Diseases
Bhopal Lancet Child and Adolescent Health
Meara Contagion Live
Ravisetti Academic Times
Blanchard Nature Biotechnology
Wu Blood Advances
Ellebedy Nature
Murray JAMANetwork
