It’s been a while since I have had time to provide a significant update but wanted to get something more substantial out to y’all in honor of starting the new school year. I hope this blog finds all having enjoyed a healthy and relatively unrestricted summer as compared with last year. Today will briefly update on disease burden, vaccination status, Long Covid, mandates, and who knows what else my stream of consciousness might target.
Starting today with a Rolling Stones clip. RIP Charlie Watts. Not a flashy drummer, but one of the absolute best.
Disease Burden Update
As everyone has noticed by now, there always appears to be a “hotbed” where case numbers are “exploding.” The media invariably will find some way to blame that localities management of restrictions as the underlying reason for their suffering. Usually that bend is serving some political purpose. Currently, the “hotbed” is the South. While it is true there is correlation with vaccination status, it is not a fair statement to blame it for the case burden. I just returned from a family trip in Disney. It was BLAZING hot. If I were a local, I would be indoors enjoying my AC or perhaps outdoors in a pool. Instead, like all the other Northern tourists there at this time of year, I walked for miles on end to be entertained, losing multiple pounds per day in water weight. Remember where the “hotbeds” were in January? The North you say? Shocking! People were indoors there at that time cause it was too darn cold to be hanging outside. Correlation or causation? You decide. I lean primarily on the latter end of that one.
Hospitalization rates in areas of high case numbers are also very high, along with ICU rates. The death tally is also starting to pick up in those areas, not surprisingly. Overall, nationally, the case numbers are about 2/3 of what they were in January. Deaths are about 1/2 the number they were at that time. My speculation as to why death rates are not tracking case numbers is that a larger percentage of the high risk population is vaccinated at this time. Even in the South. More on this in a bit.
By the way, the daily death toll for the nation is 1500 people. This far into a pandemic, this number continues to be obscene. And I think many are numb to this already. Probably because as a nation we are far better at arguing about conspiracy theories than actually looking at data and making rational decisions. Oh yeah, before I forget, and wake up call out number one today…more than 90% of the current deaths are preventable.
Cases again abound on Long Island. Whereas over 1500 cases were being diagnosed daily last winter in Suffolk County, we are seeing roughly 500 per day on average over the last several weeks. Hospitalization rates are more elevated again as well relative to earlier this summer. Over the last several weeks, a little over 200 folks have been hospitalized at any given moment in Suffolk County. This is far higher than the 50 or so that were hospitalized earlier this summer, but far fewer than the 900 or so that were hospitalized on any given day back in January. Similar story with deaths in Suffolk County. We are again witnessing them daily, but not the double digit numbers that were common in January. For an interactive view of this data, have fun on Newsday’s COVID Tracking site.
Dead and Company at Hershey Park a couple of weeks ago performing Mr. Charlie. The band has been firing on all cylinders. Can’t wait for the Wrigley Field shows this weekend!
This is a topic that we have not explored much to date with these updates. Part of the reason is that it is poorly defined. In addition, it has for the most part not been addressed much with respect to children.
The reported rates of “Long Covid” vary wildly. Some reports peg the percentage at a 2-3%, others at 30%. For now, let us just say they are significant without providing a number. The most common feature/symptom is fatigue. Not just a bit tired, but utterly wiped out. And not fixed with some extra shut eye. Nearly as commonly reported is cognitive dysfunction or “brain fog.” While these symptoms correlate with the legalization of marijuana in many states, rest assured they are not selecting stoners for these reports. Other fairly common symptoms are chest pain, breathlessness, headaches, body aches, dizziness, heart palpitations, GI symptoms, skin changes. Basically, it can involve nearly any body system or function. Overall, not fun.
Long Covid appears more prevalent in the older age groups based on a study in the UK. In that study, long Covid affected 2.1% of those aged 35-69 years, 1.6% of those 25-34 years, and less than 0.5% of children 2-16 years of age. This is not surprising, as Covid does consistently affects older folks more than the youth. Another study, published in Lancet reported 4.4% of children having symptoms of Covid persisting longer than one month.
The moral of the story here is that while we have generally addressed hospitalizations and deaths with respect to Covid, we need to start addressing the fact that there are folks who simply suffer with prolonged illness. There again appears to be age dependent risk associated with these prolonged symptoms. This is yet another reason to get vaccinated, especially for the younger age brackets who are not at high risk for hospitalization or death. Dealing with symptoms for months on end from a virus is not entertaining.
Pink Floyd performing Comfortably Numb
The FDA has now granted full approval for the Pfizer vaccine against Covid for those older than 16 years of age. Those 12 to 16 years of age are still approved under emergency use authorization while the trials in children are ongoing. Expecting full approval for the Moderna to be coming soon. Now that there is full approval, the push to mandate vaccination is well underway.
Overall, in the United States 51.4% of the population is fully vaccinated against Covid. There continues to be a significant difference in vaccination rate based on age. The elderly in our population (above 65 years of age) are over 80% fully vaccinated. The young adult population (18 to 40 years of age) is less than 50% fully vaccinated. That rate in the young adult population is rather disturbing as they are not innocent bystanders with respect to this illness. While they are hospitalized less frequently and less likely to die, both are real potential outcomes. Long Covid as was previously mentioned is quite common for this age group and results in significant life disruption.
The rate of new vaccinations has again been picking up recently. This is because fear motivates, and the Delta variant has induced fear in many.
It is worth noting that while there are significant regional differences in vaccination rates among younger adults, the elderly are consistently vaccinated in all parts of this country. In the current hotbeds of cases such as Florida and Texas, over 80% of the elderly are fully vaccinated. The Mayo Clinic site has a very nice presentation of this data.
The studies regarding the vaccine and younger children are still ongoing. Results are expected before the New Year, with some setting the expectation as the end of October. There is significant pressure being applied by the government to expedite the process. As long as that expedition is performed by minimizing the “red tape” and not by compromising the integrity of the study and its resulting data, this is welcomed.
I have been asked often as to why these clinical trials for the vaccine in children were not performed earlier. I did not find an official reason; however, I would suspect that the decision was made because children are at low risk for severe disease and that is the measured end point of significance. This reason would be compounded by not wanting to take the risk of significant side effects for a population at low risk for severe disease. Remember children cannot consent themselves, so an abundance of caution should be taken before enrolling them in trials. And for the record, I do believe this was done by all the vaccine manufacturers.
There is currently debate regarding booster doses of the Covid vaccines. Before delving into the debate, there are some conditions for which there is no debate and a booster dose is already recommended. These conditions are immunosuppressive in nature. Specific qualifying conditions are listed in the attached article from Johns Hopkins University.
So what about folks without immunosuppressive conditions? Do folks need a booster dose?
Some currently feel that the booster is not needed. The basis for their opinion is that there is not sufficient data in the general population that the immunity provided by two doses is waning. In addition, the opinion is based on the premise that the degree of protection conferred by the two doses is sufficient. A nice viewpoint article from this vantage point was recently published in The Lancet.
Others feel that a booster vaccine is needed. The basis of this opinion stems from Israeli studies involving over 1 million individuals over the age of 60 years that demonstrated a booster dose reduced the number of confirmed infections as well as cases of severe disease more than 90%. Yes, that is in addition to the protection already afforded by two doses.
The CDC is to be making recommendations shortly on this topic. My expectation is that they will be recommended for the higher risk population much like the initial cohort to receive the vaccine. I would not be surprised if they were also made available to the remaining population based on their safety profile while data continues to be collected regarding all risk groups.
Gary Clark, Jr performing “When My Train Pulls In.” He’s performing at the Paramount in Huntington in November. Great live performer.
This is the easiest section to write today. Vaccination protects against getting Covid. It protects against being hospitalized due to Covid. It protects against dying from Covid. That protection is more than 90% in all cases.
For those of you that are visually impaired, let me make that perfectly clear.
Vaccination protects against getting Covid. It protects against being hospitalized due to Covid. It protects against dying from Covid. That protection is more than 90% in all cases.
Should Those That Had Covid Get The Vaccine?
Current recommendations are that everyone of age should get the vaccine. But do you really need it if vaccinated?
The basis for stating that the vaccine is not needed if natural infection has occurred comes from studies demonstrating that natural infection provides better protection from infection with Covid relative simply getting vaccinated. The issue with this view of the data is that it ignores two factors. First, the data is somewhat short-term in nature (those infected in January/February of 2021) and it is unknown whether the findings will persist with a longer time period of study. Second, and not completely unrelated to the first point, those that were vaccinated after natural infection demonstrated higher rates of protection than either natural infection or vaccination alone.
My feeling is consistent with the current recommendations. The premise is that administering a vaccine with little risk associated to gain significant additional protection from a life threatening disease is worth your while. This is in particular the case if you are in a higher risk group to begin with.
For those out there that are thinking that you should try to get infected to get better immunity than the vaccine and may be able to “opt out” based on natural infection, please remember that you have to survive that infection unscathed.
Lastly, since you know I like to get geeky with you, there is some science emerging that helps to explain why this is occurring. Greaney, et al compared the antibody responses against Covid infection between vaccinated individuals and those who contracted the illness the old fashioned way. They found that those who were vaccinated produced a response that was more targeted to the receptor-binding domain (RBD) of the SARS-CoV-2 spike protein. More interestingly, the antibodies targeted a much wider array of targets on the RBD. This could explain part of the “added benefit” of vaccinating after natural infection.
New Side Effects
No new major concerns have been identified with respect to the COVID vaccines which continue to have an excellent safety profile. Of note though, there are studies being initiated to look further at reports of menstrual irregularities post vaccination. There are no expectations to be identifying a major concern here. This study received rapid funding primarily because anecdotal reports have been getting a lot of attention. Per Diana Bianchi, director of the NIH’s Institute of Child Health and Human Development: “Our goal is to provide menstruating people with information, mainly as to what to expect, because I think that was the biggest issue: Nobody expected it to affect the menstrual system because the information wasn’t being collected in the early vaccine studies……..There was an urgency to it, the fact that this was getting so much attention. We were worried this was contributing to vaccine hesitancy in reproductive-age women.”
I have been encountering an increasing number of parents who have themselves been tracking their antibodies against COVID and requesting testing for the same for their children. Do yourselves a favor and stop doing so. They are a near meaningless test based on the current commercially available technology. The reason why is that they are not checking for the presence of neutralizing antibodies. They simply check for any antibodies that recognize the virus. You can have antibodies on the test and no protection against COVID. This may change with technology as they develop assays, but for now these tests have no validity for making treatment decisions, including vaccination.
Picture this as kind of like a police lineup. You don’t ask the witness if the person had a face. You want to know it was the face they saw. Maybe not the best example because of all the mask wearing these last couple of years. Unless you go just by the eyes…..
What would addressing Covid be if not mentioning mandate wars? What are your rights? Do you have the right to make poor decisions?
My view? Sure you have the right to make poor decisions. If they only affect you of course, and possibly those who have consented to the ramifications of your decisions.
I remember as a kid folks smoking in supermarkets, airplanes, restaurants, and nearly every indoor space I can think of. And then it was banned. Why? Because it harms people. Wanna smoke in your house? Who gets harmed? Only you and those who choose to live with you. Enjoy. Simple.
So what right do you have to spread a deadly infectious disease at work, store, restaurant, or public space? None.
Also to consider, the harm is not limited just to the folks infected with Covid. Currently there are situations where hospitals are being overrun and no longer able to manage more traditional concerns such as a heart attack. This week a story circulated about a man who died from such after being turned away from 43 hospitals that were packed with Covid cases.
Masks in Schools
If you are asking scientifically whether masking our too young to be vaccinated children in school is among the safeguards we should take to bring this pandemic to its knees, the answer is yes.
But this question should not be answered in isolation. Who ultimately is the main recipient of this masking protection? Teachers, parents, and others at increased risk for severe disease. Especially those that refuse to vaccinate. Most of them not taking many other safeguards in their personal lives. It is certainly not saving tons of young children’s lives.
What’s the harm though? Not physical. However, I already think our youth is having increasing socialization hurdles relative to prior generations due to the electronic environment they are raised in. Adding the inability to read facial responses during the prime years they learn to socialize is only going to add to their burden.
I can only appeal to the adults in the room to do what they need to protect themselves and others. It will also permit our kids to be kids again. And limit the number of tests, quarantines, and disruptions of their education and social opportunities.
My two cents anyways…..
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.