Monday, December 27, 2021

Omicron: Zombie Apocalypse or the First Hint of Daylight?

I know it's been a while. This past semester has been truly one for the books, as I have been on 50%+ overload as we have been bringing our Nursing Program back up to full speed in the wake of some changes in faculty. I am looking forward to a "regular" spring semester on my usual workload--maybe I'll have the time to post a bit more often as we enter this next "surge"!

Ok, why the quotes around surge?

Because I think this is going to be short lived and less catastrophically destructive than previous viral variants. Here's why...

Genetics Has Rules

One concern as been that the Omicron variant might be more pathogenic--more prone to cause severe disease--as well as more transmissible. I believe this to be unlikely for several reasons. First, when microbes mutate, they tend to get some new, better features that make them more competitive from an evolutionary perspective. That comes at a cost. They gain some capacities, but lose others. I saw this with HIV. As we introduced drug treatment, drug-resistant variants emerged in people, especially if they were not very good about taking their meds consistently. We observed that those drug-resistant variants were less fit, that is, less competitive with "wild type" variants of the virus. 

I've been seeing cases of COVID-19 lately that confirm my expectations. We have evidence from elsewhere in the world that Omicron is ripping through populations faster, but also causing less severe lung disease, less hospitalization, and less death, ultimately. Homeopathically, I'm seeing more cases of mild disease that tend to improve with a repeat doses of patients' constitutional remedies, rather than severe disease that calls for more acute remedies like Bryonia or Eupatorium. This experience has been been reported by my teachers at the New England School of Homeopathy, who see a lot more patients in their full time practices.

I think a second reason that bears review is that the immune repertoire of the human race has now been exposed to several rounds of SARS-CoV-2 in its various mutations (Alpha, Beta, Gamma, Delta...), and many have been immunized as well. I'm reasonably certain that many of us have "caught" covid more than once--with the first experience being the most memorable, and--for most of us--the subsequent experiences being "the sniffles", a brief sore throat, or nothing at all. Notwithstanding, some "breakthrough" infections in previously-infected and/or immunized folks have happened, but as a group the "known survivors" of covid (I am one) and the immunized (yep, me too), have generally not been the folks clogging up our hospitals and ICUs.

Humans came programmed to deal with coronaviruses, and in the millennia since our emergence, our exposures to that family of viruses has only increased our immune competence. The current pandemic only serves to broaden that immune competence, and indeed there are data to support that this is the case. It makes sense, then, to speculate that at some point people in general will continue to suffer periodic bouts of COVID-19 as it continually moves through populations as a now-endemic virus. Early data suggest that it's also reasonable to expect that disease will not be as serious, and that fatality rates will decline. 

Bugs do what bugs do. Cholera will always be cholera. The common cold will always be the common cold. Bugs are structured in ways that create predictable disease states, but those disease states can be modified by public health measures (eg, testing, quarantine, treatment, vaccination). Ebola is an example. In poor countries with strained medical resources it is very deadly. It's less deadly in resource-rich settings. Still deadly, still the same disease pattern (eg, a lot of bleeding), but modified by the level of health care available. 

There are differences, too. Cholera doesn't mutate much. Cold viruses do. So cholera the disease stays pretty much the same, but a vaccine is easy to design. Cold viruses are less deadly, but also harder (or impossible) to design enduring vaccines for.

The common cold still kills people, but those it tends to kill are either very old, or have other medical conditions which compromise their recovery. SARS-CoV-2--"covid"--is a bit more lethal because of certain genetic characteristics. MERS (Middle East Respiratory Syndrome, caused by MERS-CoV) is still a bit more lethal for that reason as well. So while we can expect that more people will be more immune to the serious effects of SARS-CoV-2 due to worldwide, repeated exposures (and vaccines), this will not change the "more lethal genetic features" of the virus. But it will be blunted, and I think we can expect to see death rates decline.

Why do we still have the common cold? Because it's been around forever and is caused by a number of different viruses, including rhinoviruses and coronaviruses, but their genetics limit who is likely to suffer the severest disease. Their tendency to mutate to evade both previous immunity from exposure and to thwart the development of any successful vaccine mean they're endemic, but their genetics also limit how many of us will die from the common cold.

The genetics of SARS-CoV-2 make it bit more troublesome, but that trouble will be modified by our immunity as it grows over time. 

The Flu is an Exemplar-Case

The flu existed before the 1918 Pandemic, but the mutations that led to the really bad, really deadly flu of that era made it around the world. It became endemic. Now, each year virologists try to identify the genetic specifics that mark the next dominant strain so they can grow vaccine products that will confer some extra immunity. However even the vaccinated may still get the flu--just usually not as bad. The unvaccinated will too, but in all cases death rates seldom exceed 0.5%, and mainly in vulnerable people. SARS-CoV-2 will, I believe, unfold in the same way.

All of what I'm saying here is known immunology and virology. That somehow SARS-CoV-2 is "extra special" defies what we already know about how these things behave. I do understand the initial fears that this could become something very deadly and endemic--it was a crazy time back in spring 2020!--but much of the panic about the future of COVID-19 was driven by unscientific speculation. Granted, when this virus was new to everyone, before human immune systems had time to adapt to it, death rates were much higher, but even that makes sense, if we consider the example of the 1918 Flu Pandemic. The flu rarely kills even the unvaccinated now.

But when the coffins were piling up, it was hard to make that heard. Now we have two years' experience, and we can see that COVID-19 is looking a lot more like the 1918 flu, and so we are reminded that Nature follows rules.

The Case for Homeopathy

Because I keep my practice deliberately small, I haven't seen as many cases as some of my colleagues. Given the scope of the pandemic, I don't think I could have maintained my university job growing new nurses if I had gone "all in," and heaven knows we need more nurses!

What I have seen conforms to reports from elsewhere: 

  • People who are doing well on their remedy are less likely to get sick with covid in the first place.
  • Those who present with early covid, and get the correct remedy, recover more quickly and are less likely to suffer "long-covid."
  • The vaccines work, and people who get them mostly don't have much of a problem beyond a day or two of feeling crappy. This is what I've seen with flu shots too.
  • People who are newly on a remedy for a serious chronic condition are advised to wait a bit before getting the vaccine or getting "boosted." Once we know what's working and they seem healthier, then the risks are more manageable.
  • Some people get immunized and suffer vaccine injury, but it's uncommon. I've seen this with flu shots as well. The only difference now is that covid is still fairly deadly, but...
  • The lethality of covid--especially among the previously exposed (whether by disease or vaccine or both)--is less now than it was in spring 2020.

At this time, I am still recommending vaccination for COVID-19 unless I have a reasonable suspicion of vaccine injury from a prior dose (this doesn't include just feeling crappy for a day or two afterward), or a person is newly in treatment for a chronic condition.  I don't know what I'll be advising much later in the future, and it will depend on how this plays out. If it does as I expect, I'll probably be advising people much as I do about flu shots: it's an individual risk analysis question. What I'm not yet certain about is what that analysis might look like. 

That's all for now. With my lighter teaching schedule this coming semester, I hope to be posting a bit more often.

Be well!

Monday, September 6, 2021

Nature's Way: What COVID-19 might teach us about modern society

"Is it safe?"

The chilling words of Dr. Christian Szell asked as he tortures Thomas Babbington with a dentist drill, wanting to know if it's safe to get his stolen diamonds, in the 1976 film Marathon Man. It's the question many have been asking for over 18 months in the slow torture of the COVID-19 pandemic. Is it safe?

It has never been safe. Disease, accidents, the unexpected wait for us at every turn. Each day we quietly calculate risk to benefit estimates as we engage in a hundred little things. Driving our car to the store (1 in 107 chance of death). Having an alcoholic drink (9-21% increased risk of various cancers). Eating sushi (roughly 1 in 12,500 persons annually, all foodborne illness). Jogging along a highway (3 deaths per 200,000 persons annually). Simply living in a society with a lot of firearms (lifetime odds of assault with a gun 1 in 315, death in mass shooting, 1 in 11,125). 

Risk of death by COVID-19 currently? About 1 in 50, or 2% in Pennsylvania as this is written. A report from Connecticut in August shows the death rate among unvaccinated persons in February 2021 was 20 times that among vaccinated individuals; by August that has closed to 1.68 deaths per 100,000 versus 0.73 deaths/100,000 in unvaccinated versus vaccinated persons, respectively. The 2%? That's based on cases not persons overall. 

From: Cited article in link

So what's this mean?

Back in the spring of 2020, I expected that once SARS-CoV-2 was free to roam worldwide, it would remain in the population indefinitely. Unlike its predecessors, SARS-CoV-1 (case fatality rate 11%) and MERS (CFR 37%), we didn't keep a lid on the virus that causes COVID-19. In the former two events, 2002 and 2012 respectively, governments engaged in rigorous efforts to keep case spread contained. In the case of COVID-19, things got away from us, mostly because of politics--both in China and the US--I'm not picking sides here. Once it was out in the world, it was too late to keep the lid on it. It's now going to be a permanent part of life on planet Earth.

But there's some good news in this, if you want to call it that. Angus Chen, with WBUR in Boston shared this story recently. It echoes what I was thinking more than a year ago, thinking that was based on simple epidemiology: When a new germ invades the human home, it's going to either burn out, be defeated, or operate in the background at a lower level indefinitely, often after some period of intense and deadly activity. Human infectious diseases "burn out" when they kill all of their victims, and they cannot survive in any host other than human. It can be said that killing 100% of victims is not a survival strategy that works well in nature. It's more of theoretical thing than an actual phenomenon. So let's examine the other two.

We defeated smallpox with immunization. Smallpox requires human hosts to survive, and if you immunize almost everyone--as we did in the 20th century--the germ dies out. It was hoped that we would defeat COVID-19 with immunization or herd immunity or medicines, but this has not happened. And before you assume you know where I'm going with this, let me be clear that this isn't about more people getting their shots. I argue that even if we had done so, SARS-CoV-2 was never going to go away.

This is partly because SARS-CoV-2 can also live in other creatures that humans come into contact with. This is true whether one believes it escaped from a lab accident or occurred as a random jump from animals to humans in the wild. It's partly true because of lower immunization rates. It's true because some people can't get immunized, or won't develop immunity because of their genetics (not a lot, but enough). And it's partly true because no matter how many shots people get, immunity isn't going to be perfect. In his interviews with epidemiologists, Chen learns that this is the case, and confirms what I expected. What it means is that we're going to have to learn to live with a little risk.

We do it now, live with risk

At the outset, I shared ways in which common, often enjoyable or useful things pose risks to our survival. We accept those risks because the consequences of not doing so would inhibit our lives in some way. When SARS-CoV-2 led to the disease COVID-19, and people were dying at a high rate, we justifiably freaked out. Coffins piled up in New York...

Photo: LA Times

Hospitals were packed...

Photo: Intermountain Healthcare

If we didn't do something, society might have ended up like Will Smith in the movie Legend.

But even as we reconciled ourselves to the task at hand, we started asking about the costs to the rest of our lives, our mental health, our ability to make a livelihood, our children's education. I asked this in a research article I published in 2020, and I wasn't the only one. We've now reached the point in which we've put out the worst parts of the COVID fire and we're trying to figure out how to deal with an aftermath that will not be what we hoped for--an absence of COVID.

Rather we're going to have to live with it. That doesn't mean living with stacked coffins and exhausted nurses and doctors, however. Living with it is going to mean making realistic estimates of changing risk, risk that's likely to decline over time, and balancing those things society needs to move on to against the risks of causing outbreaks we cannot handle.

Why risk is likely to decline over time

In the news we're led to believe that immunization is the only route to the state of equilibrium I described above. Others resist immunization, preferring to "take my chances" with natural immunity--having the disease and surviving it--or through the use of drugs like ivermectin or Regeneron's antibody treatment. Both are risky strategies. I wouldn't put Regeneron antibody into my body unless I was literally at death's door. I'll take a homeopathic remedy, thank you! (And I did...and I got the shot--at least the shot is more homeopathic than the antibody treatment). Now I don't have room here to sort out everyone's personal risk calculus, so I'll leave it at that.

Thinking about this predicted state of equilibrium, though, we do have to consider the following:

  • Natural immunity from having COVID-19 will contribute to reduced spread, and to reduced likelihood of fatal disease--despite what the CDC and others say about the importance of giving vaccines to people who had and survived COVID-19. 
  • Artificial immunity--vaccination--will also reduce spread and fatal disease rates. 
  • Excessive immunization may buy us some marginal benefits in reduced spread and fatalities, but could also discourage people from getting the shots because repeatedly immunizing people does cause symptoms and suffering. Don't expect this controversy to end for a few years though. It takes time to learn how a vaccine will work and design a plan around that data.
  • The immune system in most people shows that re-exposure to SARS-CoV-2 reactivates latent immunity in memory B- and T-cells. I've written about this elsewhere
  • As more and more of us develop a repertoire of genetic "memory" of SARS-CoV-2, it will become less deadly, and less likely to make us really sick. How much less? That remains to be seen, but it could come to rest at or slightly above the level at which the flu kills people each year. 
  • And most important: these points are all basic immunology, and known virology concerning coronaviruses.
I don't want to over promise here. There are some unknowns, including viral mutations and the base level of virulence of SARS-CoV-2. It does mutate, and it did kill a lot of us. On the other hand, its capacity to mutate isn't limitless and is likely to resemble that found in other viruses in the corona family. Moreover, virulence tends to decrease over time in some infectious agents, especially as a population develops this immune memory I discussed above, and this is virus-specific. For example, we're better at surviving the flu than we were in 1918 (immunized or not), but because of the peculiarities of HIV, without medications, untreated HIV is still almost universally fatal (and there still isn't a vaccine for it). SARS-CoV-2 is likely to skew more toward the flu than HIV, however. 

Time will tell if I'm correct.
Stay safe (enough to still move on with your life!)

Sunday, August 22, 2021

And COVID throws cold water on the summer

I see my last post was in May...I guess I just kind of didn't feel like steeping myself in covid all summer and maybe just live life. Wasn't it great? 

And then there was the delta variant. What happened?

All germs evolve over time. Some faster than others, and to do so they have to have "little germ babies"--or replicate. If they don't replicate, they don't evolve. I've heard some of the talking heads discuss other variants, but officially the first 4--alpha, beta, gamma, and delta--are the only ones listed with the CDC.

Booster Shots

Recently the US government issued recommendations that people who got the Pfizer or Moderna vaccines ought to get a booster 8 months after their last shot. There's no recommendation yet for the Johnson & Johnson vaccine yet. The statement was jointly issued by a lot of the names you know: Walensky, Fauci, David Kessler, Rachel Levine--you, the usual suspects.

Ok, maybe that's a little snarky, but not entirely tongue-in-cheek, because I've known some of these names for a long time, and some are more recent, but all of them are caught up in a complex web of forces that they can't always control or balance. Yes, they "look at the science", but they are all still creatures of a political apparatus that can shade things, twist others, or force choices that may or may not always be the right things do do.

The Department of Health and Human Services recommendation discussed above came out August 18th. This article in Nature came out August 4th. It's a summary of what we actually know about the need for boosters, and it basically says: not sure yet. So I have to ask: did the "science" suddenly change that much in only 14 days? I doubt it. I have some notions about why this booster thing came out.

Waning Immunity

Immunity can decrease over time. We already know this, but the extent to which immunity declines varies over time, and depends, in part, on how much a germ mutates with each generation. For example, smallpox is very genetically stable, so smallpox vaccines work pretty much forever.(1) While for HIV we haven't been able to develop a vaccine yet--that virus displays every known mutation every 24 hours, so chasing it with a vaccine is like a dog chasing its tail!

What about covid? Research suggests it mutates more than the flu but much less than HIV.(2) It's taken about 13-14 months for us to see the delta virus to really get out there, so yes, the coronavirus has been changing, but not at breakneck speed, and I argue that a lot of this was because for more than a year we didn't have any way to curb the spread other than isolating from each other.

The best data shared in the Nature article from August 4th basically concludes "we don't know yet" whether booster are needed, and when. They do say that immunization still protects us very well from severe disease. Some of the scientists who were interviewed for the article believe, "A small dent in the efficacy against infection does not justify, in my view, someone like me getting a booster when someone else has not even had one dose." Much of the science around boosters is based on theory, observations, and population data that may have other explanations. It's not very strong science; but it's making some people nervous. 

So yes, boosters will "boost" immunity that has fallen a bit, but a lot of people, including the World Health Organization, argue that the marginal benefits of additional shots don't justify their use in this way. They further argue that we really ought to focus on getting the vaccine-hesitant in the US, and the vaccine-poor around the world, their first shots!

I agree. So why is the HHS recommending boosters?

The 4th Surge

We're in a weird time. The virus is definitely causing problems. Almost everywhere is Pennsylvania, transmission of covid is rated as "high". You've probably had it again and didn't even know it. You caught a whiff. It got in your nose and generated several thousand copies, which you may have breathed out into the air. But within hours to a day, your immunity smushed those little germs and recycled the proteins...and the bonus? That probably also boosted your immunity too!

So one concern is that "breathing out some virus" part. Obviously that poses a hazard to people with little to no immunity against covid. That's a concern. It's why you're seeing masking orders in some settings. I work at Penn State, which instituted an indoor mask rule just a week or so before we started back to work. 

Why no stay-at-home orders? No social distancing requirements? No lockdowns? Simple: We can't do that forever. Some people are locking themselves in again. I can't argue with that; it's a personal choice in my view. But I do think--as much as I hate it--that present circumstances warrant some additional caution, and indoor masking seems a reasonable caution. I don't mask indoors unless it's requested. Last week I noticed Lowe's wants people to mask in their stores. Home Depot hasn't yet. I wear a mask at Lowe's, but not at Home Depot. I still shop both stores.

My personal calculus: I had it in early 2020. I got my shot in mid-2021. I'm good. What about other people's safety? Well, based on my reading of the research and my deep knowledge of immunology, I can say with confidence that my little whiffs of covid are probably more harmful to the unimmunized than to the majority of Pennsylvanians who are immunized (54% overall, 68% first dose). I figure that people who want a vaccine but can't take it are masking and maybe even isolating and taking all those precautions. And people who avoid vaccines for reasons other than legitimate medical necessity? Well, as I said: people are going to engage in their own risk assessment. Unfortunately, a lot of those assessments seem to have landed many people in the ICU--or the grave. 

Really, I don't think there's any turning back. This thing is going to go around and around indefinitely. Some people are going to die. Most won't. Over time our systems will continue to develop better and better resilience to the virus. It won't be "herd immunity" as much as it will be "endemic equilibrium." The flu's been killing people for centuries, and we don't spend half the year in space suits. At some point, people have to go on with life and frame risk behavior in those terms.

But the surge is real. In areas with low immunization rates, hospital ICUs are at capacity. Health care workers are burning out. Here at Penn State we're growing new nurses as fast as we can. Hospitals are taking students again, and even letting students work in high-risk settings--as long as proper protective gear is used. Again, we have to move ahead, and now hospitals are reframing their risk calculus in this way: "We'd like to stop the spread...but, we have to move on and get back to business...or there won't be anymore nurses and doctors to replace the ones who have had enough suffering--or died--during this pandemic."

The Surge and Immunity Science Intersect with Politics

So there you have it. Surging infections. Filling ICUs. Resistance to more lockdowns and isolation and business closures. That's the politics behind the booster recommendations: "Let's try to goose immunity to buy some marginal gains against viral spread--plus it'll look like we're doing something!"

In the meantime, the poorer parts of the world go begging. And just where do they think the next strain of virus will come from? Harrisburg? York? Lancaster? Nope, it's going to come from Egypt, Philippines, and Venezuela. I was disappointed in the current administration's public recommendation for boosters in the US, where 60% have been vaccinated. I don't blame it on Joe Biden, though. He's just going along with his experts' advice--his name was not on the HHS report. But I do feel that he and HHS and CDC are bending to the will of what may be a majority of Americans who are still anxious enough to demand more shots. I think it's short sighted, but then history tends to show that people aren't especially focused on the "long view." 

What I'll Tell My Patients

There's actually not much that really prevents people from getting covid vaccine. A new patient on a new remedy for complex problems? I might say "Let's wait a bit before getting the shot," or "Get the shot first and come back and see me in a month or so." Complex medical patients like diabetes, heart disease, etc? "You probably ought to get get your shot." The immunocompromised? That depends. Active cancer chemotherapy? Maybe wait. The use of drugs like steroids or Humira? You probably ought to get it. It might won't work as well, but probably beats doing nothing. Each case is different, but the bottom line is this: there are fewer safety exceptions than many people believe.

Right now, I think it's important to stick to the original plan: most folks should get their shots. I don't think it's an ideal personal health solution, but so far I've observed the hazards seem pretty manageable. Honestly, I have yet to see a case where a patient was clearly, chronically harmed by any of the vaccines, even though I know it happens sometimes. But a booster? I think you can wait. Let them examine the data with better methods and over more time first. Individual cases may vary, and I'll deliver that advice individually. 


1. Josefson. BMJ. 2003 May 31; 326(7400): 1164.

2. Callaway. Nature. Sept 2020 at 

Saturday, May 15, 2021

"Ding dong the witch is dead!" The CDC Throws Cold Water on COVID

Time for an Update! 

Image from:

First, I did get immunized, and I did so with the Johnson & Johnson/Janssen product. I did not die.

I did get nervous one night a few days later at 3 AM when I had a headache--"Oh no! I'm getting cavernous venous sinus thrombosis!" (What a mouthful of words to think in the wee hours!)

No, I wasn't. I probably had a headache because I wrenched my neck doing yard work earlier. But I'm human too. I can freak out. I just have so much more technical knowledge with which to both scare myself, and with which I can calm myself down. Back to sleep. Woke up at 7. No headache. I'm fine.

What's Changed for Me?

Not much. Even with the CDC's updated guidance, it'll be a few weeks before we see what happens with masking requirements, social distancing, and all the little things we didn't notice constituted "normal" until this episode. I do feel a bit privileged. As I reported in my previous blog, immunization against COVID seems like a badge of good citizenship, a shield, a fashion that's in-fashion, and I've begun to notice that people toss "It's ok. I'm vaccinated," or "I had my shots," into conversations. To reassure? To brag? I'm not certain. I've done it with my patients. It seems like a kindness, and says "There's safety here." 

Unless you're someone who wasn't that worried in the first place, or if one has a political point of view about COVID safety that supersedes such precautions. Writing in the Philadelphia Inquirer, Allison McCook says that the change in CDC's masking guidelines don't provide any answers concerning those who might un-mask even though they are unvaccinated. She shares,

I’m not only afraid — I’m angry. Because I was really looking forward to not being afraid anymore. That, to me, is what “normality” and freedom feel like. That’s why I circled May 25 on my calendar [for her second shot]— it was the day I could stop feeling afraid that I would catch or spread COVID. And now I feel like that date is meaningless. Because even when it comes, I’ll still be afraid — not for myself, but for the future of this pandemic

She then closes with this,

So I’m still going to wear a mask, even after May 25. Please don’t yell at me about it, or accuse me of fearmongering or some weird conspiracy plot. I’m just scared

A month ago, Derek Thompson wrote in The Atlantic that deep cleaning of surfaces isn't a "victimless crime"--harmless "hygiene theater" that makes us all feel safer. It actually costs us money, time,  and effort that could be better spent on measures that actually reduce risk. His main question is: Why did it take so long for the scientific establishment to get on this bus? My answer is: "theater." 

Much of managing a public pestilence is about managing the public mind. The theater is still open for shows because that's the show so many people want to see. They're scared.

It will be interesting to see what happens. Will there be a surge? Was this change too soon? On the other hand, how much more can people take? The introverts in the world may have loved the enforced cocooning, but many of us see the risk as acceptable--and perhaps necessary. After all, how can we say the vaccine will change everything when it began to appear it had changed nothing?

This was the calculated risk of a risk-averse organization, the CDC. In a time of year when people feel expansive--springtime--their numbers still seemed to indicate a reduction in case rates and fatalities. It's reasonable to attribute this to two things: a lot of people had COVID and are immune, and a lot more people got artificial immunity from the vaccines. If this is indeed the case, you kind of have to give a little ground.

Vaccine Passports

Without these, it is argued, who knows who is and who isn't immunized? That's a fair argument, but also an impractical argument: The American social character isn't disposed to a "show me your papers" way of life. And if we have learned anything from this pandemic it is that you can only enforce limitations to the extent that there's a political path to do so. The culture and economics of an America, a South Korea, a China, a France, an India have had more impact on how things have evolved in these places than anything we have done with vaccination, medicines, or bleach. 

Vaccine Avoidance

I heard from one of my patients about vaccine adverse events. It wasn't an alarming note, just meant to be interesting, and so, interested, I dug into the Vaccine Adverse Event Reporting System (VAERS) back on April 11th. The database reported on 117 million doses of all products administered as of April 5th, with 57,000 events of all kinds reported. This works out to an adverse event rate of about 0.049% or about 1 event for every 2000 doses given. I'm not talking sore arms here. These are reported events: people have to go to the trouble to submit a report, even though anyone can. So a lot of minor issues probably go unreported, but were probably already known from the original research.

"Serious" events, including hospitalizations, deaths, and other really bad stuff occurred at a rate of about 0.006% or about 1 event for every 15,000 doses administered. It was at that point that I closed the loop: As I said previously, I was waiting for enough accumulated data to determine if something really weird was going to emerge.

It didn't.

Yeah, I hear people talking about potential "long term" harms, but they generally are unable to be specific about these. As I note in an article on my website from March 2008, it's certainly possible that vaccines can cause subtle, complex harms. But as I have aged and become more experienced, I have learned that there are so many possible ways to these subtle, complex harms, including ongoing toxic stress, too much sitting, climate change, pesticides, air pollution, doom scrolling, racism, processed foods, medical marijuana, and bourbon! So many things that I have to ask: after 117 million doses, and with these risk ratios, does it really matter if I get this thing? 

True, I could have been that one-in-a-million that gets the dreaded "brain clot", buuut...I wasn't. 

Recently I lost a brother to a horrific, aggressive, Burkitt's lymphoma that likely resulted from 15 years' exposure to immune-suppressing drugs he had to take because he was a kidney-transplant patient. His experience made death from COVID seem trivial to me. I'm not trying to minimize anyone's pain if they lost a loved one to COVID. I'm simply contrasting a very public, common, and scary phenomenon (COVID), one that is beginning to fade, to a very private--and sadly ordinary--event that touched me personally and influenced how I feel about life in a time of pestilence. COVID meant we couldn't visit in groups at the end, but it was a side show compared to the main event: cancer.

While Chris' death was sudden--from start to finish it was only 6 weeks--and awful, if he hadn't gotten the transplant, he would have spent a good part of the last 15 years on dialysis...and it's very likely he would have died within 5 to 10 years--surviving longer is rare because of the risk of infection as well as just how hard it is on the body when you can only filter off the toxins a few days a week.

And so, while I'm aware of the possible weird, subtle harms that might emerge from the shot I got at Rite-Aid a couple of weeks ago, I'm inclined to ignore them. It's all about risks and benefits. I chose mine. It seemed a reasonable choice.

Choose well.

Thursday, March 25, 2021

COVID-19 Immunity and Vaccination: An Update From the Front

I've been away from the blog for a while, as it's been a very busy semester! But things have calmed down and I'm back.  

"Should I get the vaccine?"

This is the question of the moment in my practice. To some this may seem odd. Who wouldn't want it? People are "jumping the line" and engaging in all sorts of cheats to get their shots. I heard a woman interviewed on NPR recently who said she wept when she got hers, she was so relieved to have been vaccinated.

So who wouldn't want this? 

Today we're talking about "vaccine hesitancy" which is, I believe, a kinder and more accurate term than "anti-vaxxer", which has also gained popularity as description of online communities and public antagonists who ardently oppose artificial immunization. The latter are a diffuse and widespread group who believe that vaccines are bad for health, and some who argue that vaccine programs are a plot against ordinary folks, a plot by drug companies to get money, a plot by governments to sicken or control people. 

I've stated elsewhere in this blog that artificial immunization generally works as it is supposed to, that in a sense it mimics homeopathy in its approach to disease reduction, that its value is often overstated by its promoters and understated by its opponents, that it has had less effect on population health than improved sanitation and nutrition have, and that in some it can lead to enduring negative health effects, but that predicting who will suffer such effects is difficult. As I have noted elsewhere, it can confuse early homeopathic treatment, but most people seem to do ok. In the end, it is a risk-to-benefit analysis that must be calculated by the person considering immunization. 

"Ok, ok...but should I get the vaccine?"

There are two things to consider here. The first is protection from future disease, and the second is the social climate around this disease. The first feature is the easier to navigate, so let's address that now.

There's been a lot of mixed messaging around immunity from SARS-CoV-2--the "coronavirus". Of course there are many coronaviruses, and some cause the common cold, so it's likely many of you have had a "coronavirus" before. Some are more serious, and it's true that novel viruses, like SARS-CoV-2, and its cousins SARS-CoV-1 and MERS-CoV, often caused more severe disease in people because they are new. We come into this world with a set of instructions for beating most of the common germs, and even instructions for some things not so common. But these instructions vary in their detail. Once exposed to some germ or another, those instructions for generating an immune response to that germ are revised, refined. Next time we come into contact with it, we're likely to respond better and faster, and may not even get symptoms at all.

This is one reason COVID-19 has been more lethal than the flu or common cold: we didn't have the best set of instructions for developing an immune response. Nevertheless, many people who "got" COVID didn't get too sick, or they got pretty sick but got better without having to be hospitalized. A lot of people git very sick, and many died, and sometimes this was because of immune senescence (older folks' immune systems decline in effectiveness), general poor health (obesity, diabetes, heart disease, etc.), and--sometimes--bad luck. It would be silly to ignore the fact that some otherwise perfectly healthy people in good shape got "the 'rona" and just died. Some day we may discover some genetic or other peculiarity that explains this, but right now, we just have to accept that there is vulnerability across the lifespan, even if that vulnerability varies somewhat.

I must add that some germs are just more deadly for reasons other than or in addition to their novelty in people. So of them are just bad--keep that in mind as well. COVID-19 seems to be staying at around 1-2% mortality, so it's still more deadly than a cold or the flu. 

Given the facts of the case, lacking immunity to this coronavirus--whether naturally acquired (had the disease) or artificially acquired (immunized)--poses at least some risk. The vaccine rollout addresses this pretty well. Frontline health workers and older people are first in line. Viewed another way: people constantly exposed to sick people, and the folks most likely to die from COVID need to be considered most at risk and they get the shots first. There are controversies about prioritization..., but let's not get into that here. You get the basic concept.

"I had COVID. Do I still need the vaccine?"

The short answer from my perspective is: we don't know. Currently, public health authorities recommend it if you're in an eligible group. They say this is because we don't know how long natural immunity lasts. Some experts suggest natural immunity isn't as durable as artificial immunity, but the science is murky, and some experts argue that natural immunity comes with significant risks, but if you already had COVID and survived without any subsequent health problems, that safety concern is moot, and it's likely immunity will persist for a time. It's possible that natural or artificial immunity will be similarly durable, and right now we don't know what that durability is...three months? A year? Two years? 

And as the virus evolves new versions of itself, will we have protection from those? Early research suggests, yes, probably. Again, for how long? We're not sure. So for now the message from most experts is: "When your turn in line comes up, get it!" regardless of whether or not you already had COVID.

I've been reading research reports and right now there's evidence that we don't maintain antibodies for longer than three months after infection. Antibodies are chemicals our immune cells make to bind to germs and deactivate them promptly, but you have to have been exposed to the germ at least once, first. "Circulating antibodies" have been considered a medical measure of immunity to infectious diseases. For example, my students sometimes have to get them checked for things like measles or mumps, to see if they need a booster shot before entering nursing school. 

With this pandemic, there's been intense interest in memory cells. When we get an infection, B- and T-lymphocytes--types of white blood cells--"learn" the nature of the novel germ. They use this pattern recognition to develop effective, targeted responses to beat the infection. They also generate a few copies of cells that don't join the fight. Those cells just go hide out somewhere until it's over. These are memory cells. They remember the pattern so that the next time that germ shows up, they can quickly generate new antibodies and new killer cells to mop up the problem fast, sometimes without even any symptoms! 

We've known about this process for decades, but this level of interest in it is new, and happening because of the pandemic, so you can't go to Quest or LabCorp and get your memory cells tested! It's all just research at this point.

But we now know something important that we didn't really think about before: that circulating antibodies are not the only measure of immune defense. Indeed, we now have some research that suggests this response, what immunologists call the "anamnestic response", may be more important to COVID immunity than how much antibody is swimming around in your blood. The latest research suggests this may be at least 8-12 months. I include links here for the science nerds, Rodda, et al. 2021, Quast & Tarlinton 2021. This isn't comprehensive, but gives an idea.

"And soooo?"

Right now, I'm telling people that if they had COVID within the last year or so (the period of time we have at least some evidence for), and if they want to wait a while, it's probably ok to do so. Why wait? One doesn't have to, but some people are, rightfully in my view, a little cautious about a brand new drug and a brand new technology (mRNA vaccines) until a little more time goes by. That's their personal risk-to-benefit analysis.

I'm also inclined to have people get immunized if they have special vulnerabilities (age, disease) and they have not already had COVID.

A Little Bit About the Actual Products

Pfizer and Moderna make COVID vaccines with this new technology. So far it appears to be fairly safe, and something like 90 million have been immunized in the US with at least one dose of this 2-dose regimen, so it's looking pretty good--notwithstanding that a lot of people have reported to me that they got some uncomfortable symptoms (fatigue, fevers, chills) from them. This has also been widely reported in the media. So I find people setting aside a day to recover from their shots, especially the second one. I've seen some people miss a day of work for this reason. 

The Johnson & Johnson and Astra-Zeneca products use a more familiar technology that uses DNA in a harmless virus to do the same thing in one shot. I don't have as many reports to work from, but so far it seems the side effects are less bothersome. It's hard to say what's going to happen with Astra-Zeneca's product, as there have been controversies among experts about its effectiveness, so it isn't available yet in the US. However both of these "DNA-adenovirus" products seem to be very effective at preventing serious disease. Overall, the 2-shot mRNA vaccines seem a bit more effective than the DNA-adenovirus vaccines, but the latter require only one shot and may have fewer side effects. 

"Are you going to get it?"

That's a question I get a lot. People figure that if the alternative medicine homeopathic guy gets it, there must be a good reason. It's complicated, and that takes me to the social issues surrounding mass coronavirus immunization.

I believe that having been vaccinated will become a marker of sorts for whom to trust, who can come into our "bubbles", who is a "good person" and who is a "bad person." I believe the collective mental scar from this past year and over a half-million people dead will become an enduring driver of public opinion, occupational policy, medical approaches, and administrative law. I don't know if it will be permanent, but already I am hearing about companies that will require vaccination for in-person work. I'm sure my incoming class in the fall will all be required to have been immunized in order to be in the nursing program. Hospitals will be even more dictatorial about corornavirus vaccination than they have been about flu vaccination. If immunity turns out to be long lasting, those demands may fade with time, but by that time, most Americans will have been vaccinated, either by choice or because they had to in order to keep their jobs, their place in school, and so on.

I don't believe that every school and every workplace will require it. That's harder to enforce, but I predict that it will become common for many social points of contact to demand proof of immunization before a person can [fill in the blank] with "get a job", "stay in school", or "fly on a plane" as examples. 

There will be resistance to this effort for sure--this is America, where we are often contrarian by dint of our culture! But you can bet there will be change.

More interesting is that I have begun to see individuals share that they will only consort with people who have been immunized. There's a lot of fear out there, and I'm not saying it is unjustified, but fear is on a spectrum from "foolhardy disregard" to "paralyzed panic", and I wonder how many folks are at the "paralyzed panic" end of the spectrum, and thus how common shaming of the unvaccinated might become, and how it will amplify our already-agitated social state. 

Somewhere on that spectrum is "wary regard of potential hazard"--That's where a lot of people are. That's where I've been. 

I have seen a lot of shaming of people not wearing masks. Some of those unmasked folks might be in the "foolhardy disregard" category, but some of them have medical issues that make mask-wearing difficult or dangerous--yet they too are shamed, because we see a thing and we form an instant (and uninformed) opinion. I am betting the same thing will happen with coronavirus vaccination status. One can easily see that choosing to get the shot may come down to concerns other than one's health, or risk-to-benefit analysis!

So, will I get the vaccine? If I do, it'll likely be the J&J product; I prefer drug tech that's been around for a while to tech that's brand new. That's just my experience after 30 years of practice. But will I get it, you ask?

Well, let's just wait and see.