Header photo is of “Starman” driving in a Tesla Roadster.  It was part of Elon Musk’s tribute to Bowie when completing the first successful deployment of payload with the Falcon Heavy in 2018.  The car continues to orbit the sun to date with Bowie’s “Space Oddity” playing on continuous loop.

“Pressure pushing down on me

Pressing down on you, no man ask for

Under pressure that burns a building down

Splits a family in two

Puts people on streets”

– David Bowie (Under Pressure, 1981)

Under Pressure

For all of us that were hoping 2021 would bring with it some semblance of normalcy, we can at least take solace in the fact that there are still a little over 50 weeks left for that to occur.  This country continues its trend of polarization and degradation of societal fabric, and to say the least, it is disturbing to witness.  Don’t fret, today’s blog is not going to be some political diatribe.  Nor will I get religious on you.  What I will ask of you, is to try to keep in mind that humans have not fundamentally changed in the last couple of decades.  No matter how different we all may appear, we all have the same primary goals – food, shelter, and hopefully some love in life.   There is little more in life that is that black and white.  The rest is the gray area, and we are collectively losing touch with that.

This week I will provide a brief update on the COVID-19 data as always.  Will also be catching folks up on some of the science that continues to help us understand how to manage both COVID-19, as well as future pandemic situations.  As vaccination for COVID-19 is underway, it has become yet another polarizing hot topic. Will try to provide some guidance on that topic as well.

Today’s featured artist if you have not already guessed is David Bowie.  Today marks the fifth anniversary of his passing at age 69, after a nearly two year battle with liver cancer.  My first introduction to his music was when I was in preschool hearing songs from the album Young Americans while rolling around in the “bus.”  The “bus” for school was actually a station wagon, with most of us piled in the back eating candy the “bus driver” gave us while she pumped out tunes.  Yep, no car seats, seat belts, and all eating choking hazards.  Gotta love the 1970’s.  By the time Lodger was released in 1979, I was totally hooked.  Rest in Peace David, and thanks for all the years of self-inflicted acoustic trauma I have enjoyed as a result of your music.

This video is for the song Lazarus, off Bowie’s final album, Blackstar.  The album was released two days prior to his passing, and is one of his finest.  

Color by the Numbers

National Picture

Despite warnings, much of America let pandemic fatigue get the best of them for the holiday season.  The consequence of such is beginning to materialize now.  Records are made to be broken, but unfortunately we are doing such on a daily basis.  Today’s WHO report includes 313,516 cases diagnosed yesterday in the United States.  That is the first day we have cleared 300,000.   Also per the WHO report, we have already seen 20,000 fatalities this week due to COVID-19, including days with more than 4,000 deaths, both records in their own right.  What is in many ways more disturbing, is that it is guaranteed to worsen over the next couple of weeks.  Those that travelled for Christmas gatherings and acquired COVID-19 were likely still without symptoms when they returned to mingle with others for New Year’s celebrations.  Those folks then returned to work on January 4th to add some kerosene to the dumpster fire.  This upcoming week should start to reveal the impact with respect to number of cases.  Hospitalizations and death tolls will not be evident for several weeks yet.

Suffolk County Status Report

The local picture is similar to the national.  Case numbers, hospitalizations, and deaths are all trending in an unfavorable direction unless you are the owner of a funeral parlor or are paid to write eulogies for a living.  The pictures, from Newsday’s COVID-19 tracker, below speak for themselves.  Suffolk County releases daily data on hospital capacity.  Currently there are 661 beds available (20% of capacity).  Of those, there are 68 ICU beds available (16% of capacity).  We are approaching a level that is going to create significant problems to manage ANY condition, COVID-19 related or not.   This has already occurred in California.  Last week, the Los Angeles County Emergency Medical Services (EMS) Agency made recommendations to not transport by ambulance certain types of illness or injury to the hospital as they would not be able to assist. They are also have oxygen supply issues.

On the topic of non-COVID-19 related health concerns, be aware that influenza season has officially begun in Suffolk County.  There were 32 confirmed cases (0.9% of tests performed) this week in Suffolk County.   There are other counties in New York though that are currently exceeding a 10% positive rate, so it is just a matter of time now to start seeing more significant influenza burden here as well.  You can track influenza rates on the New York State website.  If you have not gotten your influenza vaccine yet this year, this would be a very good time to do so.

Heart’s Filthy Lesson was released on the album Outside in 1995.  The live clip of this song is from David’s 50th birthday bash at MSG.  The first time I heard this tune live was at the Electric Factory in 1997.  To have had the privilege of seeing David perform from mere feet away two nights in a row was a treat I will never forget.  Especially since I found someone recorded the show.  Go ahead, play Where’s Waldo and see if you can spot me.  

Time for Science

“The good thing about science is that it’s true whether or not you believe in it”

Neil deGrasse Tyson

Introduction

Will break down this weeks science lesson into broad topic summaries with links for anyone who feels like delving into any topic a bit further.  Will be covering a bit of epidemiology and effects of government interventions, immunology, therapeutics,  and vaccinations.  Time to get your inner geek on.

Epidemiology and Government Interventions

Recently there has been some focus on the emergence of new strains of COVID-19 that appear to have the ability to spread faster, in particular one from the United Kingdom.  Please note, faster spread does not always correlate with worse disease, but it certainly increases the number of folks that are infected. This strain has already found its way to the United States (including New York), and has likely spread further than we are fully aware at this moment.   Seeking to read more about how they identify variants and rates of spread?  If so, click here for an article by Volz, et al, in Cell that addresses just that.  While on the topic of spread, the concept of measuring an R-value has been discussed in prior posts.  In short, the higher the R-value, the greater the spread.  A great video shared by a local colleague exemplifies this concept extremely well using crochet (thanks Lisa).

There is considerable research at this time regarding COVID-19 spread and the effects of various mitigation strategies.  First, it appears that some people are really good at spreading the virus relative to others.  This paper by Sun, et al in Science looked at data from contact tracing in Wuhan, China and found that 15% of primary cases were responsible 80% of secondary cases.  In more plain English, this means that a select few people were responsible for large scale spread.  While there are “superspreader” events, most actual transmission of the virus occurs in the home setting.  What you essentially have is a few really good spreaders in a public place sending folks home to go contaminate their entire household or apartment complex. Before we jump to the conclusion that full stay at home orders are therefore indicated, the science does not support such a conclusion.  That being said, “closing all educational institutions, limiting gatherings to 10 people or less, and closing face-to-face businesses each reduced transmission considerably” was the conclusion drawn by Brauner, et al when looking at the effects of governmental interventions on spread of COVID-19.  The authors went on to state that “The additional effect of stay-at-home orders was comparatively small.”  In “keeping it real” terms, you don’t have to stay home all the time, but by minimizing significant size gatherings and outside face-to-face contact with others does have a real impact.  With respect to educational institutions, there was no distinction made as to age group.   It is my suspicion, as opposed to data based commentary, that the majority of educational institution spread is at the college level with decreasing effect based on younger age.  Based on what is seen in our office, we have yet to see spread among classmates or classmates and teachers in a primary school setting.   College kids have been a completely different story in our experience.  Ever wonder what happens when “keeping it real” goes wrong?  Dave Chappelle can help you with that.  Warning, if you don’t know who Chappelle is, he is a comedian, and pushes the envelope a bit.  Quite a bit.  Still curious? Click here. 

Last for this section, if you want to try to estimate your personal risk of contracting COVID-19, there are multiple tools for you to do so.  Read this article in Nature regarding some of the apps designed with this in mind.

Vaccinations

Currently there are two mRNA based vaccines approved under Emergency Use Authorization that are being administered in the United States.  Others should be coming shortly.  I am happy to report that it has been over a week since getting my first dose and only I can complain about is that my arm was pretty sore for a day and a half with some mild nerve pain radiating towards my elbow.  Perhaps a bit of fatigue, but that is tough to really assess since I have forgotten what a day off means during this pandemic.  The experience of those I know that have received the vaccine has been similar.  Those who already had COVID-19 that were vaccinated tended to have slightly more soreness, fatigue, and in some cases fevers as well.

Efficacy and side effect profiles for both the Moderna and Pfizer vaccines were published in the New England Journal of Medicine last week.  No serious side effects were reported.  These studies do not obviate the need for ongoing monitoring for side effects and assessing long-term efficacy. There have been vaccines that have made it to market in the past prior to identifying issues.  A nice perspective piece on this topic can be found here.  What I can state at this time with a very high degree of confidence is that if you are in a medium to high risk category for severe COVID-19 related infection, your risk-reward ratio for taking the vaccine is skewed very much towards taking the vaccine.

We have addressed the micro-chips and lack thereof in the vaccine previously.  Again, to be clear, THERE ARE NO CHIPS in the vaccine.  Not micro, not chocolate, not butterscotch.  If you buy into Big Brother or Big Pharma placing them in the vaccine as part of a grand plan to harm you, you may already have a chip loose.

Another major concern that has been raised recently regards impaired fertility and the COVID-19 vaccine.  There have been NO STUDIES SHOWING IMPAIRED FERTILITY FROM THE COVID VACCINE.  There is however a social media posting circulating trying to postulate such.  This post has been debunked, but we all know how well that works once it has already been circulated to millions.  Worried that the Associated Press and “liberal media” are part of the scam?  Then I will refer you to an extremely thorough Q & A on the COVID-19 vaccine courtesy of the “red state” of North Dakota.  Apparently the right and left can meet in the middle on some topics.

Lastly, there have been concerns about severe allergic reactions.  These have in fact occurred.  In the United States, they have occurred at a rate of one such reaction for every 1.4 Million doses given.  I am not even going to start listing the daily activities universally engaged in that carry higher risk than that.  Also worth noting, these reactions are manageable with an Epi-pen and they are kept on hand at the administration sites should they occur.  It is recommended that folks getting the vaccine wait at least 15 minutes if not a half hour after the administration to monitor for such reactions so that they may be safely addressed should they occur.

Immunology

As we are now a full year into this pandemic, we are beginning to learn what type of immune responses occur in response to COVID-19 infection and how long they might persist and provide protection.  There have been case reports of individuals getting COVID-19 a second time.  Fortunately, these continue to be the exception rather than the rule.

An article by Dan, et al, in this weeks edition of Science looks at five separate antibody and cell-mediated immune response parameters to infection with COVID-19.  They found that most (64%) of infected individuals were positive for all five parameters 1-2 months post infection.  By 5-8 months post infection, the majority of these individuals remained positive for all five parameters of immune response.  Perhaps more importantly, 95% of infected individuals still were showing positive responses to at least 3 out of 5 parameters.  Why more importantly?  Because you do not require all five parameters to successfully fight off a viral infection.  Another study recently published confirmed the robust presence of antibodies five months post-infection with COVID-19.

Those with milder infections also appear to maintain their immune responses to COVID-19.  This does not address why their infections were mild, only that their responses were sustained.  A couple of studies were published in Cell over the last couple of weeks addressing this topic.  The first by Chen, et al looked at antibody responses only.  The second study conducted by Rodda, et al, looked at antibodies as well as a few other immune related parameters.

Since the beginning of this pandemic, children have been less affected.  This is likely for many reasons.  One reason may be that common seasonal coronavirus infections are more common in this age group, and that the response to such provides a degree of immunity to COVID-19.  Ng, et al addressed this topic in an article addressing pre-existing immunity to COVID-19.

While the above studies all have in common looking at responses people had in a positive sense, there are other studies that are trying to identify those at risk for severe disease.  The studies come in several flavors.  First are studies looking at actual individual responses to infection.  Other studies are focusing on genetic predispositions.  These genetic studies make use of CRISPR technology.  Sound familiar?  Yes, this is the same technology we discussed some weeks back in the Girl Power post.

Regarding studies that looked at actual responses to infection, one performed by Zohar, et al found impaired humoral immunity (aka poor antibody response) in those with severe disease.  Larsen, et al found a specific type of antibody response correlated with severe disease.  Another study by Karki, et al, conducted reviewed data in humans related to cytokine production (they cause inflammation) and inhibition of such in a murine (mouse) model.  The authors concluded that those with lower inflammatory responses (or that have those responses blunted) are more likely to have a better outcome.  Studies like this have value as you may elect to be more aggressive with treatment if you could identify higher risk individuals sooner.

Will not delve into detail on the genetic studies today.  Suffice it to say, they all look to identify host factors that lead to different outcomes when faced with infection.  A summary of CRISPR as it applies to this particular strategy by Bailey and Diamond can be found here. If you wish to delve further into this topic, feel free to take a peek at a few studies addressing this (Daniloski, et al, Wang, et al, Schneider, et al, and Wei, et al).

Therapeutics

There are no new therapeutics to discuss at this time.  Antibody therapies are being utilized for certain risk categories under emergency use authorization and I am unaware of any significant follow up studies since their use as such began.  There are a couple of novel therapies on the horizon however.

First are nanobodies.  Nanobodies are essentially a portion on an antibody that can be used to neutralize a virus.  Xiang, et al explored these in a llama model whereas Schoof, et al did so in a yeast model for COVID-19 infection, both with positive results.  What is exciting about nanobodies is that they are capable of being administered via a nebulizer (ie: inhaled) rather than requiring injection or infusion.

Linsky, et al explored the use of using “decoy proteins” to treat infection with COVID-19.  Rather than using antibodies to neutralize virus, this treatment strategy would involve using portions of the natural ACE receptor COVID-19 binds to.  Binding to a these portions of receptor do not permit COVID-19 to enter cells, effectively acting similarly to a neutralizing antibody.

These studies are early as yet with respect to development, but represent novel therapies that could be used for other viruses as well going forward.

Above is the music video associated with one of my favorite David Bowie songs off the Lodger album.  This was made prior to the MTV era.  

Parting Thoughts

Wishing all a happy and healthy new year!  With a little luck, we will all move past this pandemic over the next several months and return to our regularly scheduled programming.  Part of doing so is going to involve letting go of pre-existing bias and moving forward looking at data.  The politicizing of this pandemic has been catastrophic and the blame gets placed squarely on ALL our “leaders” be they Democrats or Republicans.  I will refrain from any blow-by-blow description of the incompetence I witness daily as it will serve no purpose.  I beg our leaders and populace to start looking again to the center, not the extremes.  Regarding the pandemic, we need to protect those at risk, and do so without destroying the livelihoods or well-being of others in the process.  Easy task?  Of course not.  Capable of being accomplished?  Yes!  We need to ensure that the COVID-19 vaccination program results in getting needles into the arms of those at high risk as quickly as possible.  Every delay of even one day leads to unnecessary death.  Simply addressing that population solves the largest portion of the problem.  And yes, we need to monitor to results and act appropriately as we widen the scope of who will receive the vaccine.  Legislating/mandating discussions are counterproductive at this time, and I am not suggesting we ever go there.  Don’t confuse that last statement with limiting access of at-risk (ie: non-vaccinated) to certain situations. As an example, I would not want a caretaker of elderly in a nursing home non-vaccinated and working through their “cold.”  Identifying problems, developing and offering solutions, reexamining the effects of those solutions is called learning.  When done in open and honest transparent forums, it is easier to have people make well informed decisions.  Most people can get there (with the possible exception of the flat-Earther’s).  Stay safe all!

Post authored by Jason Halegoua PhD, MD, MBA, FAAP.  Jason is the founder of Peds First Pediatrics in 2009, and has been a practicing general pediatrician since completing residency at Schneider Children’s Hospital in 2004.  In addition to earning his medical degree from the Medical College of Pennsylvania, Jason earned a PhD in Molecular Pathobiology for his work contributing to the understanding of the genetic regulation of immune responses to murine leukemia viruses from Hahnemann University in Philadelphia and an MBA in Finance from Hofstra University.