Volume 11, Letter 25 Coronavirus Update 37
June 7th, 2021
The United States is now past 63% of its over 18 year old population having been vaccinated with at least one dose and 42% of all Americans fully vaccinated. The number of vaccinated and or previously infected Americans is now a very large number and cases have flat lined nationally. We have had no positive cases in our office for 10 days which is a first since the pandemic began.
136 million Americans are fully vaccinated with most being higher risk. 169 million have had at least one dose. The vaccines continue to drastically reduce the risk of death and hospitalization.
North Carolina now has 78% of individuals over 65 years of age fully vaccinated. It has stalled here.
The vaccines continue to be effective against all of the variants.
As it stands today, the United States has had 33.4 million cases and almost 597,000 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.
Great news has arrived in 2 new studies: see number 5 below: "immunity in convalescent individuals will be very long lasting and that convalescent individuals who receive available mRNA vaccines will produce antibodies and memory B cells that should be protective against circulating SARS-CoV-2 variants" (Wang et. al. 2021)
1) Sequelae following a moderate to severe COVID infection continue to plague medical systems. In a new study in the British Medical Journal, we see a 14% increased risk of developing new onset clinical conditions.
"14% of adults aged ≤65 who were infected with SARS-CoV-2 (27 074 of 193 113) had at least one new type of clinical sequelae that required medical care after the acute phase of the illness, which was 4.95% higher than in the 2020 comparator group. The risk for specific new sequelae attributable to SARS-Cov-2 infection after the acute phase, including chronic respiratory failure, cardiac arrythmia, hypercoagulability, encephalopathy, peripheral neuropathy, amnesia (memory difficulty), diabetes, liver test abnormalities, myocarditis, anxiety, and fatigue, was significantly greater than in the three comparator groups (2020, 2019, and viral lower respiratory tract illness groups)." (Daugherty et. al. 2021)
Parsing through the tea leaves of the study showed us that the majority of the patients that had new clinical issues were admitted to the hospital with COVID19, were older and had pre existing conditions. However, younger individuals without any pre existing conditions have also fallen into this category mirroring other studies looking at these issues.
Another study by Hirschtick and colleagues also found increased post COVID issues in a significant number of people. Women had 56% of the concerns and trended to older age. (Hirschtick et. al. 2021)
2) Is Covid infection and/or the Covid vaccine affecting women's menstrual cycles? There is no hard data yet to support a cause and effect situation with the vaccine. The anecdotal world is replete with concerns of heavy and abnormal periods. A recent Women's Health Article looks at some of the concerns. We need data at this point to answer these questions as anecdotes are nothing more than just that.
One study by Li and colleagues noted a change in menstrual length and or decreased volume after Covid infection. (Li et. al. 2021)
This question is yet unanswered. The reproductive system of a female is intimately tied to the immune system making it highly plausible that individuals with significant inflammation post vaccine or infection could have transient hormonal shifts leading to changes in menstruation and sense of wellness. To be determined but also highly unlikely to be a problem.
3) Looking at the male side of hormone balance, a study in JAMA noted that low circulating male sex hormones, testosterone in particular, are associated with a worse Covid outcome. There was an inverse association between testosterone and Covid disease severity. (Dhindsa et. al. 2021) Just as with estrogen and progesterone for women, testosterone is tightly wound to the immune system.
Sex hormones remain a relatively mysterious part of much of immune and neurological function in humans and should be a major focus of research in the coming years.
4) "Put the Kids First" - a Washington Post opinion piece hits the nail on the head for what we should be doing for children. The article states: "Here’s one simple recommendation: Children should return to their normal lives this summer and in the upcoming school year, without masks and regardless of their vaccination status."
Contrast this statement with the CDC's guideline comments on May 28th, "Camps can safely reopen without masks and distancing if EVERYONE is fully vaccinated against Covid19." By definition, they are really stating that kids will be masked and distanced despite all of the data against this policy because everyone being vaccinated will absolutely not nor ever happen. Vaccination history in America has already proven this fact. It is fundamentally illogical to ask for every child to be vaccinated as the backdrop for easing policies that are really no longer necessary based on all of the past 14 months school based transmission research, circulating viral volume and childhood disease risk. Yet, somehow, the CDC, our most trusted source of infectious disease information, says exactly that.
It is high time we look at the negative realities of children's mental and physical health in a Covid precaution based fear centric policy system that prizes the health of vaccine refusing adults over the health of low risk highly sensitive growing children. The opinion piece also states rightly, "Overall, the risk to children is too low to justify the remaining restrictions they face. Somewhere between 0.1 and 1.9 percent of covid-19 infections in children result in hospitalizations — and that’s likely an overestimate given that recent studies suggest approximately 40 percent of pediatric covid-19 admissions were misclassified. The risk of a child developing MIS-C, a serious inflammatory condition with effective treatments, is less than 1 in 1,000. The virus has claimed the lives of nearly 400 children in 17 months, lower than the estimated deaths among children in recent influenza seasons." See 9 below for more on MIS-C risk.
5) Vaccination may offer long term or even lifelong immunity from severe disease.
Study one: Wang and colleagues looked at 63 COVID-19-convalescent individuals assessed at 1, 6 and 12 months after infection. 41% of these post infected individuals also received mRNA vaccines. "In the absence of vaccination antibody reactivity to the receptor binding domain (RBD) of SARS-CoV-2, neutralizing activity and the number of RBD-specific memory B cells remain relatively stable from 6 to 12 months. Vaccination increases all components of the humoral response, and as expected, results in serum neutralizing activities against variants of concern that are comparable to or greater than neutralizing activity against the original Wuhan Hu-1 achieved by vaccination of naïve individuals. The mechanism underlying these broad-based responses involves ongoing antibody somatic mutation, memory B cell clonal turnover, and development of monoclonal antibodies that are exceptionally resistant to SARS-CoV-2 RBD mutations, including those found in variants of concern. In addition, B cell clones expressing broad and potent antibodies are selectively retained in the repertoire over time and expand dramatically after vaccination. The data suggest that immunity in convalescent individuals will be very long lasting and that convalescent individuals who receive available mRNA vaccines will produce antibodies and memory B cells that should be protective against circulating SARS-CoV-2 variants. Should memory responses evolve in a similar manner in vaccinated individuals, additional appropriately timed boosting with available vaccines could cover most circulating variants of concern." (Wang et al. 2021)
Study two: "patients who experienced mild infections (n=77), serum anti-SARS-CoV-2 spike (S) antibodies decline rapidly in the first 4 months after infection and then more gradually over the following 7 months, remaining detectable at least 11 months after infection. Anti-S antibody titers correlated with the frequency of S-specific BMPCs obtained from bone marrow aspirates of 18 SARS-CoV-2 convalescent patients 7 to 8 months after infection. S-specific BMPCs were not detected in aspirates from 11 healthy subjects with no history of SARS-CoV-2 infection. We demonstrate that S-binding BMPCs are quiescent, indicating that they are part of a long-lived compartment. Consistently, circulating resting memory B cells directed against the S protein were detected in the convalescent individuals. Overall, we show that SARS-CoV-2 infection induces a robust antigen-specific, long-lived humoral immune response in humans." (Turner et. al. 2021)
These two studies in reputable journals are pointing to a very reassuring reality, that the majority of us will have long term immunity to SARS2 once infected and/or vaccinated with the mRNA vaccine through the development of long lasting memory immune cells. This is so exciting for someone that does not want to see a world where we have to have boosters annually or even every 3 years. Whether vaccine alone can do this will take years to answer likely.
6) Viral load and viral cell culture can help predict which patients will be the 8 to 10% of highly infectious SARS2 patients that cause 80% of cases. In a well done study in the Journal Science, we see a data set looking at risk of transmission. The highly infectious individuals come in all shapes and sizes according to this study. "Our results indicate that PAMS, pre-symptomatic, asymptomatic, and mildly-symptomatic, subjects in apparently-healthy groups can be expected to be as infectious as hospitalised patients at the time of detection. The relative levels of expected infectious virus shedding of PAMS subjects (including children) is of high importance because these people are circulating in the community and it is clear that they can trigger and fuel outbreaks" (Jones et. al. 2021) The new B1.1.7 variant had a 5% higher viral load than the other variants owing to its higher infectiousness.
Young children, as seen in other studies have very low viral loads. Changes occur over the years, noting higher loads beginning with adolescents and in older years. That being said, infectiousness is roughly similar between adolescents and adults based on the accumulated data to date and less than 10% being highly infectious.
"The bimodal distribution of culture probabilities shows a small group of 8.78% of highly-infectious subjects. This qualitatively agrees with a model and a study concluding that 10% and 15% of index cases, respectively, may be responsible for 80% of transmission. Other studies reported that 8-9% of individuals harboured 90% of total viral load, that in cases from India and Hong Kong ~70% of index cases had no secondary cases. The risk posed by PAMS subjects is highlighted by the fact that 36.1% of the highly-infectious subjects in our study were PAMS at the time of the detection of their infection, that their mean age was 37.6 years with a high standard deviation of 13.4 years, and our estimate that infectiousness peaks 1-3 days before onset of symptoms." (Jones et. al. 2021)
Yet again, we see how tricky this virus is with peak infectiousness days before any symptoms arrive, if they arrive at all. A small group is causing most of the infections likely related to genetic predispositions to increased viral replication and shedding.
7) Cardiac inflammation is a common finding in individuals after moderate to severe COVID19. From an article in JAMANetwork from 2020 we see: "In this study of a cohort of German patients recently recovered from COVID-19 infection, CMR revealed cardiac involvement in 78 patients (78%) and ongoing myocardial inflammation in 60 patients (60%), independent of preexisting conditions, severity and overall course of the acute illness, and time from the original diagnosis. These findings indicate the need for ongoing investigation of the long-term cardiovascular consequences of COVID-19." (Puntmann et. al. 2020)
As Covid is an inflammatory vascular disease primarily, these and other cardiac findings are not surprising. However, the variable nature of the cardiac involvement in those with mild to severe disease is a tricky phenomena. Thus, we must reinforce for all patients with a history of febrile moderately ill Covid disease that they look at the American College of Cardiology guidelines for exercise. Link
8) There is emerging information out of Israel, that the mRNA Pfizer vaccine maybe linked to cardiac inflammation in teenagers and young male gender adults. This inflammatory response known as myocarditis occurs after viral infections in rare instances and seems to be a rare but significant issue with the COVID vaccines. Science Magazine states: "In a report submitted today to the Israeli Ministry of Health, they conclude that between one in 3000 and one in 6000 men ages 16 to 24 who received the vaccine developed the rare condition. But most cases were mild and resolved within a few weeks, which is typical for myocarditis." (Vogel et. al. 2021) There may have been 2 deaths post vaccination, although these are under review.
Putting this into perspective, if a young man gets the virus, the risk of myocarditis is even higher. In one study, 37 out of 1597 athletes (27 male) or 2.4/100 had signs of myocarditis post infection. (Daniels et. al. 2021) Again, the data shows us that this virus and the mRNA vaccines are very special in both a good and bad way. Viral infections real time tend to be dramatically worse than the vaccine variety of viral protein exposure. That being said, this is the exact reason why we track vaccine related and infection related side effects to understand risk and outcomes.
Back to normal life without forgetting that lifestyle choices drive risk in all ways,
Daugherty British Medical Journal
Hirschtick Clinical Infectious Diseases
Dwyer Women's Health
Li Reproductive Biomed Online
McBride Washington Post
Vogel Science Magazine