March 30th, 2022

Volume 12, Letter 15

North Carolina like the rest of the country is now without much Covid related illness. Salisbury Pediatrics is Covid testing between a zero and 2% positive rate week by week. Influenza remains relatively infrequent. All of these stats are the lowest since the pandemic began.

The 7 day moving average of cases for the US in recent weeks has plummeted from the highs of greater than 800,000 to less than 38,000 owing to Omicron's incredible activity and burn rate. Quick up and quick down.

The risk of death is 0.000033 once vaccinated with a two dose series or survived natural infection.

As it stands today, the United States has had 80 million known cases and almost 972,000 deaths. The case numbers will continue to underestimate true case volume by 3-4x as home kit positives are not being reported including the 4 from my house in January and February.

If you did not read the newsletter about an Integrative approach to proper health in the COVID era and frankly all future infectious diseases, 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 regardless of vaccination. However,
mathematically, you now have a 99.9998% chance of survival once vaccinated and the vaccine safety for the mRNA vaccines continues to look good.

 Omicron now has three strains: newer variant BA.2 makes up 23+% of current case volume while omicron BA 1.1 is at 66% and B 1.1.529 is the rest. Delta is no longer registering a blip. Disease remains mild compared to the tough Delta strain. Little else to report here. (CDC Variants)

Europe is seeing a new wave of cases and many countries in Asia are seeing massive volumes based on little a priori immunity to SARS2. The US remains quiet - for now. If we do have another wave, it would be very surprising if hospitalization is significant after the massive omicron wave and the T cell immunity that followed.

There are lots of articles predicting a large new BA.2 wave. I doubt it, but time will tell.


Quick Hits and other musings -

1) There is much conversation around a fourth booster shot being authorized for adults and even teenagers. The logic behind who should has not changed to my knowledge based on the fact that Immunity post natural infection lasts considerably longer than post 2 dose mRNA vaccination or booster dose. Antibody related immunity last roughly 6 months post vaccine only. Natural infection plus a vaccine dose lasted well north of a year. (Hall et. al. 2022) Again, this is only antibody related. T cell activity lasts much longer and with better mutational specificity. The bottom line remains that in multiple studies now, natural infection once vaccinated or the other way around vastly trumps vaccine alone or boosters. Again, it is highly unlikely that repeated boosters makes any sense for the vast majority of us. Only, the high risk groups appear to need boosters 4 and on despite what the policy makers say pending new quality data that would change this calculus.

The safety profile of the fourth dose appears ok in very small studies and limited data sets. A recent study in NEJM noted that 154 individuals over 60 years of age received a 4th booster with no significant side effects. This is a tiny number to know the true side effect risk so take this for what it is worth. The antibody response was about as robust as dose three. Vaccine benefit against disease and symptoms was modest at best. (Regev et. al. 2022) Not much to write home about here. Minimal benefit but most likely safe for those that need dose four.

2) Covid vaccine is causing increased tinnitus cases to occur according to the vaccine adverse reporting network. Tinnitus is a perceived sound or ringing in the ears that occurs while we are awake and conscious of it, but there is no actual sound in the environment. This is likely due to autoimmune attack of neuronal networks in the hearing system or some other immune dysregulation in genetically predisposed individuals. The answer is yet unknown. This is also likely after natural infections from SARS2 as noted in PACS patients. (Ahmed et. al. 2022)(Chirakkal et. al. 2021)(Almufarrij et. al. 2021)

This issue will need more research as to the etiology and treatment. Treatment for tinnitus remains poorly effective for many.

My take remains the same, booster doses remain a great idea for the elderly, over 65, and all individuals with risk factors.

3) Moderna's vaccine for children less than 5 years old remains minimally efficacious which is similar to Pfizer's results. The benefit was not strong against symptomatic disease although safety appeared to be fine. The question remains: if your child is healthy and has had a natural case of SARS2 with no major issue, why vaccinate? I cannot find a reason to. I will wait to hear of a reasonable scientific reason to vaccinate this healthy previously infected population.

4) Vaccine safety against neurological side effects remains strong. From the British Medical Journal: "colleagues (doi:10.1136/bmj-2021-068373) studied the association between covid-19 vaccines, either vector based or mRNA, and immune mediated neurological outcomes. Neither the ChAdOx1 nCoV-19 (Oxford-AstraZeneca) nor the BNT162b2 (Pfizer-BioNTech) vaccine was associated with an increased risk of neurological adverse events. Conversely, increased risks of all studied neurological outcomes were seen after SARS-CoV-2 infection." (Pottegard et. al. 2022)

This is in line with all previous data that I have reviewed.

5) Large increase in diabetes diagnosis 1 year after Covid diagnosis and illness resolution. (Xie et. al. 2022) These results have been seen a few times now. New onset autoimmune activity post infection is worrisome from natural disease moving forward and bears more vigilant watching. To my knowledge, we have seen none in clinic to date attributed to Covid infection or vaccination.

6) A very interesting article in the New York Times about Dr. Edward Holmes and his theories that the pandemic began in a Raccoon dog in the Wuhan Seafood Market. "When Dr. Zhang got wind of a new pneumonia in Wuhan, he asked colleagues at the Wuhan Central Hospital to ship him lung fluid from a patient. It arrived on Jan. 3, and he used the techniques he and Dr. Holmes had perfected to search for viruses. Two days later, Dr. Zhang’s team had assembled the genome of a new coronavirus, SARS-CoV-2. Other scientific teams in China had also sequenced the virus. But none made it public, because the Chinese government had barred scientists from publishing information about it. Dr. Zhang and Dr. Holmes began writing a paper about the genome, which would later appear in the journal Nature. Dr. Zhang flouted the ban and uploaded the virus genome to a public database hosted by the U.S. National Institutes of Health. But the database requires a lengthy review of new genomes, and so days passed without the information going online. Dr. Holmes urged his collaborator to find another way to share the genome with the world. “It felt like it had to happen,” Dr. Holmes said. On Jan. 10, they agreed to share it on a forum for virologists, and Dr. Holmes put it online." (New York Times 2022)

Interesting article from a possible etiology perspective.

That's all this week,

Dr. M

Regev NEJM
Ahmed Annals Med Surgery
Chirakkal ENT Journal
Almufarrij International J Audiology
Pottegard BMJ
Xie Lancet Diabetes and Endocrinology
NYTimes Holmes Article
CDC Variants Page