July 24, 2021

J and J Vaccine and Guillain Barre Syndrome (GBS)

A rare neurologic autoimmune disorder (GBS) affecting peripheral nerves has been reported up to 42 days after receiving a J and J vaccine dose.  GBS is usually more common in males over the age of 50 and occurs following a respiratory or gastrointestinal infection.  Patients develop weakness and tingling in the feet and legs, then symptoms ascend to affect the upper body.  Very rarely it can follow a vaccination and in 1976 a small number of cases occurred following the H1N1 swine flu vaccine shot.  The CDC ACIP Advisory Committee met Thursday to present information about the reported cases, and there is a suggestion that it is occurring more commonly than the usual 1 case/100,000 people per year, making the vaccine a likely contributor.  It also is seen in patients with Covid-19 and the overall benefits of the vaccine far outweigh the risk of GBS due to the vaccine.  

The J and J vaccines are only a single dose vaccine, and are definitely favored by those that can't or won't miss work.  It also is easier to store and make available in rural communities, individual doctors' office, or even home vaccinations that are being offered here in NYC to the home bound.  The CDC will study the cases that were reported through their various safety reporting mechanisms and have another ACIP meeting in August.  The CDC website and fact sheets have already been updated and can be read.   

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Today there were several reports in Covid newsletters I follow about patients who were now hospitalized with Covid and asking their doctors to give them a vaccination.  One man was about to go onto the ventilator when he asked.  There was only one response - "It's too late."  Everyone is expecting the delta variant to continue to surge, with infections highest where the vaccination rate is low.  There was a recent doubling to tripling of the number of US Covid cases per day.  In NYC the delta variant in samples collected July 10, and sequenced since then, is now 75%.   The infection rate in NYC was 0.5% at the beginning of the month, 1.1% at the beginning of last week, and 1.8% at the end of the week. Be careful and stay healthy. 

July 21, 2021

The Delta Variant is Chasing the Unvaccinated

The Delta variant is now accounting for 69% of cases in NYC, from 44% the previous week.  Daily cases are definitely increasing in all 50 states, with the greatest increase in the counties and states with the lowest vaccination rates.  In NYC 98% of hospitalizations and deaths between Jan 1 and June 15th were in people who were not fully vaccinated.  Nationwide more than 97 % of hospitalizations and 99% of the deaths are now in unvaccinated people.  Our good news: the NYC Health Dept said that over 64% of NYC adults are fully vaccinated and seem to be well protected against the delta variant.

The Kaiser Family Foundation is conducting vaccination polls, since Jan. 2021, and 23% of American adults said they weren't going to be vaccinated and 25% said they would "wait and see."  As of June, approximately 25% of the first group and 50% of the second group are now vaccinated.  When asked what helped them change their minds, these were the 3 basic reasons:  

1.  Seeing that millions of Americans have been safely vaccinated.

2.  Being told to get vaccinated by doctors, friends, and relatives.

3.  Not being vaccinated will prevent them from doing more and more things.    See Below

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States and counties have tried everything to get more people vaccinated - including free college tuition in state schools (NY), a lottery for one million dollars (Ohio), a free beer, baseball tickets etc etc.  If we don't increase the vaccination rate country wide, the number of hospitalizations and deaths in the unvaccinated group will surge. 

Kate Cohen, in an Opinion piece in the Washington Post today, suggested that every newspaper, TV News, bulletin boards, billboards, etc should publish and update two numbers DAILY: number of deaths in the vaccinated group next to the number of deaths in unvaccinated people.  I think this is brilliant. It could even be in a neon sign in Times Square.  

 

July 17, 2021

Breakthrough Infections, Don't Freak Out

The Phase 3 trials of the mRNA vaccines assessed efficacy by testing participants who developed symptoms of Covid-19 and tested positive.  This is defined as SARS-CoV-2 disease. In contrast, a positive Covid test in an asymptomatic person is a SARS-CoV-2 infection.  The vaccine efficacy was 95% in preventing symptomatic disease so vaccine breakthrough cases are expected. Theoretically 5% of fully vaccinated people could develop symptomatic Covid-19 even though fully vaccinated.  No vaccine is 100% effective at blocking an infection in all circumstances.  In addition, there are immunosuppressed patients, congenital or acquired, who are at greater risk.

Breakthrough cases in people 2 weeks after their second dose of mRNA vaccines may be detected just because they are being tested regularly.  Asymptomatic infections do occur and even symptomatic disease tends to be mild after full vaccination.  The vaccine efficacy against severe disease with hospitalization and death was even higher in the phase 3 vaccine trials, but now real world deaths are being seen in fully vaccinated people, many with underlying co-morbidities.  Preliminary data in the US, over the last 6 months, suggests that 99.5% of deaths from Covid-19 have were in unvaccinated people.  See Below 

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As of July 6th the US CDC reported 5,186 cases of severe breakthrough infections in 157 million fully vaccinated people for a rate of 0.003% (4909 hospitalizations and 988 deaths). The vaccines are even demonstrating efficacy against the current variants of concern.  Genomic sequencing by the NYC DOH demonstrated that 44% of the Covid cases here were due to delta variant in data released on June 26 and 69% in data released on 7.3.  The infection rate is increasing in almost every state as the virus infects the unvaccinated - NYC and NYS cases were approximately 0.5% at the end of June and approximately 1.3% yesterday (80,000 people tested).  Other states are increasing much more rapidly and if I lived in a state or county in which the vaccination rate is low and the infections are increasing dramatically, I would continue all precautions - even wearing a mask indoors in group settings unless everyone was vaccinated.  The pandemic is not over.

July 14, 2021

The Latest Info on the Delta Variant

Monica Ghandi from UCSF wrote a new Opinion piece in the Washington Post this week and it is worth the time to review some of the main points, since the Delata Variant is now the predominant variant in the US.  "The vaccines work against this frightening new variant, and they remain our best, most powerful tool to extinguish the pandemic here and abroad."  This variant has increased transmissibility, but there is no evidence that it causes more severe illness.  All 3 vaccines in the US produce strong neutralizing antibody responses against it and the mRNA vaccines stimulate creation of memory B and T cells as part of the immune response.  Breakthrough cases are also usually mild.  See Below

 

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Israel reported a Vaccine Efficacy of 64% with the Pfizer vaccine, but "larger data sets from Singapore, Canada, and Britain demonstrated efficacy against symptomatic infection of 80-90%."  The number of cases in the US doubled over the last week, and most are in unvaccinated or not fully vaccinated individuals. 

Get vaccinated, get that 2nd shot if necessary, and stay healthy.  I hope to review the latest information on the J and J vaccine on Saturday.  We returned home from our visit to DC, where we were  able to watch the removal of all of the fences and Jersey Barricades from around the Capitol  Saturday - a very exciting day for everyone in the neighborhood who spend lots of time on the Capitol grounds.  

 

July 10, 2021

Interesting Children's Clothing Store Windows

More Pen/Ink drawings from my early AM neighborhood walks.  I stopped during the cold weather and any wet days but eventually the Covid collages and medical reading took over most of my time.  I'm going to try to take me sketchbook again with me on my walks this summer. 

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July 7, 2021

Venturing Further From NY

We are traveling a little further - taking Amtrak for the first time since early January 2020.  It will be wonderful seeing our son Jason and his family after we limited almost all activities and travel because of the pandemic.  Fortunately we saw a set of Jason's Instagram photos every night and were able to follow their family life during the entire time.  I can't wait until we get there and can squeeze and hug everyone.  There will be a break from my Covid Blog/Facebook entries and I will resume them when we return.  Until then I am posting a few of my pen/ink drawings that I did on my neighborhood walks.  Be back here next Wed.  Please be careful, there is real concern that the Delta Variant is spreading rapidly in the unvaccinated.  

A cute doll created with pipes and other plumbing "stuff" in the window of a very old Supply Store. 

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Hard to resist drawing hats and an outdoor clock over the sidewalk.

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July 3, 2021

Delta Variants - What Level of Risk to Accept?

If you are not vaccinated, you are in danger of infection by the Covid-19 delta variant.  The virus searches out the vulnerable and right now we have to be concerned about those who will never get vaccinated - as we watch Covid cases increasing in many states in the US.  Most of the cases have been occurring in the unvaccinated, and the infected group now includes a larger percentage of unvaccinated children <12 years old and a lower percentage of the vaccinated elderly.  

It is possible to be vaccinated with two doses of the mRNA vaccines and still get Covid, although severe disease is uncommon.  Both the Pfizer and Moderna vaccines had vaccine efficacy rates of approximately 95%, and slightly less with the delta variant.  And J and J just reported strong persistent activity against the delta variant for a minimum of 8 months followup of their original trial subjects.  But that still leaves a small number of people who can still be infected after full vaccination.  The vaccine efficacy against the delta variant is a slightly lower than against the original virus strain (about 90% for the mRNA vaccines) allowing mostly asymptomatic and mild breakthrough cases to occur.  See Below

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We each have to decide what level of risk keeps us comfortable.  For people who live in an area where cases are increasing, it makes sense to wear a mask indoors, even if you are fully vaccinated.  There is no good way to determine who is unvaccinated in some group encounters.  If you only had one dose of the mRNA vaccines, like 15 million Americans, the vaccine efficacy against the variants may be as low as 30-35% - and you should definitely protect yourself indoors and get your second dose.    I have been following the daily Covid cases in NY State, NYC, and Manhattan.  They now test almost 100,000 people per day as part of the Statewide Tracking Program and there are <0.5% positive cases in all 3 areas.  Genomic sequencing data of new cases is still being done in NYC on a subset of cases, and the delta (Indian) variant is increasing quickly as the alpha (UK) variant is decreasing.  Our family of 16 is all vaccinated except for 3 grandchildren less than age 12 - and my husband and I still avoid high risk indoor events. 

 

June 30, 2021

Longer Duration of mRNA Vaccine Efficacy?

The immune system is incredibly complex.  An antigen, foreign to the body, stimulates an immune response consisting of antibody production against the "invader," and activation of specific immune cells. Vaccine efficacy measures the full immune response and is measured by the number of people who get Covid 19 in the placebo group and those that get covid 19 in the vaccinated group.  B lymphocytes and plasma cells are responsible for antibody production and T helper and T killer cells are part of the cellular response to the infection, or in this case vaccine.  Antibody levels can be measured, but the titer slowly decreases over time.  However some committed B cells become memory B cells and remain in clusters in germinal centers of the lymph nodes.  Some memory plasma cells also remain after the foreign antigen is gone.

If that same foreign invader returns, these immune memory cells can be activated and stimulate another full immune response to the same virus or spike protein in the vaccine.  How long will it last last?  Sometimes for life (measles vaccine).  Investigators from Wash U. in St. Louis just published a scientific paper in Nature which demonstrates that there are both the memory B cells and memory plasma cells in active "germinal centers" in lymph nodes and they still appear active 15 weeks after vaccination.  Germinal centers in lymph nodes typically peak 1-2 weeks after vaccination and then wane.  The bottom line is exciting - we may have vaccine-induced immunity that will be more durable than was expected!  How long is unknown, but the investigators now have a way to monitor the immune response in addition to measuring antibody titers.  See Below

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In the words of the scientists reporting this data, "the studies demonstrate that SARS-CoV-2 mRNA-based vaccination induces a persistent germinal center B cell response, enabling the generation of robust humoral immunity."  More variants could change all of this, but right now we can hope that booster shots will not be needed for the foreseeable future.

 

June 26, 2021

CDC and Myocarditis/Pericarditis with mRNA Vaccines

On June 12th I wrote a blog post about possible myocarditis/pericarditis as rare adverse effects of the mRNA Covid vaccines.   http://www.paperandthreads.com/2021/06/is_myocarditis_a_very_rare_sid.php

On Wednesday the CDC scientific vaccine advisory committee met to review the reported cases that have been adjudicated based on criteria for the diagnosis of myocarditis and pericarditis.  Scientists at the CDC presented all of the data that was accumulated since their last meeting, discussed the data, and then discussed the benefits vs risks for the continued use of the two mRNA vaccines against Covid 19. The final recommendation was that the benefit of the vaccines far outweigh the risks.

The side effects occur within 1 week after the administration of the 2nd vaccine dose and are usually chest pain and shortness of breath.  Symptoms and test results demonstrate that most cases are very mild and clear within several days with treatment like Motrin.  Most of the cases occur in males between the ages of 12 and 30, with an incidence of 12.6 cases per million second doses administered.   The majority of cases recover fully.   See Below for comparative data re: the incidence of myocarditis following Covid 19. 

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A large study of Big Ten school college athletes demonstrated that 2.3% of athletes that recovered from Covid had heart abnormalities consistent with myocarditis.  CDC researchers estimated that every million 2nd doses of vaccine given to 12-17 year old boys might reduce myocarditis cases to 70, and prevent 5700 infections, 215 hospitalizations, and 2 deaths. These cardiac side effects of the vaccine are very, very rare and the consensus was that all adolescents and young adults should continue to get vaccinated.  The CDC will continue their extensive monitoring and follow these cases for 3 months.  Hopefully they will be able to better define the mechanism by which the vaccines cause the cardiac events.

 

Shirley Parker Levine
New York City

July 2021

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