2019 Novel Coronavirus (CoVID-19): Part XXIII
2019
Novel Coronavirus (2019-nCoV (first named); COVID-2019 (later named
disease); SARS-CoV-2 (final name of the virus causing COVID-2019),
COVID-2019 Pandemic:
August 30, 2021 update Part 23
Paul Herscu ND, MPH
Herscu Laboratory
Entering the third phase of this pandemic (Part 2 of 5)
A piece for those who have not been vaccinated
Hello and welcome. It has been a while since I have written. We have just now arrived at the third phase, of my understanding of the 5 phase stage of this pandemic. I imagine many of you are feeling frightened, angry and frustrated, as well as simply confused. Things have not gone as well as they should have, as we are experiencing the next increase of incidence in the USA. The question is how to proceed from where we are. I am bombarded by questions from family, friends, patients and students. I would like to discuss several major aspects to help the general discourse. This is a difficult task as at this time as there are two paths, one for those who have been vaccinated and one for those who have not been vaccinated. As a result, I would like to break down the writing into 5 separate posts. They are:
1. A piece for those who have been vaccinated
2. A piece for those who have not been vaccinated
3. A piece on effective natural therapies
4. A piece on other pharmaceuticals
5. A short recap
Herein, I begin with the second piece, for those that have not been vaccinated:
While this seems like a simple category, it is far from simple. There are many reasons why someone has not gotten vaccinated. Here are some: Individuals who have a religious prohibition to all vaccinations, those who have had severe adverse events from prior vaccines, people younger than 12 years for whom the vaccine is not yet tested, those undergoing medical treatment where vaccination is not recommended at this time, people who cannot afford the vaccine, people living in regions of the world where the vaccine is not widely available, people who are too old or too infirm to mount a proper response, those who have a philosophical opposition to all vaccinations, people who do not want to be forced by the government to get vaccinated, people confused by a variety of misinformation and are therefore afraid of getting vaccinated, people who already caught the SARS-CoV-2 virus, and people who are averse to anything new.
As can be seen there are a variety of folks that may have very little to do with each other, aside from not having been vaccinated. They are not all the same. At its most extreme, some in this group don’t want this vaccine and some are desperate for this vaccine, but are unable to get it, for one reason or another.
In general, this group will change over time due to these four changes that will take place over the coming months. First, as the vaccine supply increases, those areas of the world who were unable to afford or to have access to the vaccines will be able to, and this subgroup will shrink. Second, the more days that pass, both with the virus and the vaccine, those folks that are generally averse to new things, who may well be late adopters to anything new, will become more accustomed to the concept, and so this group will diminish as well. Next, as areas that were previously spared become hotspots, and as these hotspots show a differential attack rate of those not vaccinated versus those vaccinated, more and more of those who were confused by misinformation mixed with political rhetoric will get vaccinated, and this group will shrink. However, as the virus continues to mutate, and there are more and more reinfections, I believe the repeated booster program will not be as successful as the first vaccine, and the group that took the first vaccines but not the booster group will grow, rather than hold steady, and therefore eventually fall into the unvaccinated group.
First off, let me address the topic of time, in the midst of epidemics
As we teach on the topic of epidemics, there are three very important fundamental variables. Perhaps the most important one, in the midst of an epidemic, is time. You have to do the right thing at the right time for it to have the outcome desired. This is not a dichotomous yes/no situation. Doing the right thing, but at the wrong time, as in being late to do something, is no longer the same action. Context is everything. And in an epidemic, things change enormously over time. If you have 100% of the population get vaccinated, but it takes 10 years or even 2 years, that is not the same as getting 100% vaccinated within 6 months. You will achieve a different outcome in these diseases where the virus mutates, and the antibodies do not last. A completely different situation. This is one of the things I meant in the last post when I brought up the booster program proposed. I think, as a program it will fail, due to poor communication. Because of time, we will have three large groups, though many subgroups. The three large groups will be: never vaccinated, had the vaccine but no longer immune, and currently vaccinated with the latest boosters. On the face of it, it sounds simple enough, but in fact there are numerous latent subgroups, groups that are not known, because of our society’s refusal to test regularly. These subgroups include: never vaccinated but have ample antibodies from prior infection that was known; never vaccinated but have ample antibodies from prior infection that was so asymptomatic, it was not known; vaccinated without booster but have enough antibodies; vaccinated without booster and do not have enough antibodies, vaccinated with booster and have enough antibodies, vaccinated with booster but do not have enough antibodies. You see what I mean. This is a more complex story than simply vaccinated or not? Booster or not? And really the way to tell is to test and keep on testing, which I will come back to in a moment.
The reason I bring this up has to do with the points mentioned in the last post. This form of disease has a constant mutation but also has a constant diminishing of the antibodies towards that infection, both after vaccination or after natural infection. In other words, time plays a crucial role in understanding where we are in regard to our immune status. The more time passes, the less protection you have from the prior infection you had or from the vaccine. Time passing leads to real consequences.
A great deal of reporting and many studies compare groups. For example, vaccinated versus unvaccinated. What would allow these studies to be more profoundly accurate is to classify when the vaccination took place. For example, comparing someone who had the disease 14 months ago to someone who had the vaccine 2 months ago is sort of silly. Likewise, if you compare someone who got vaccinated 16 months ago to someone who got the natural disease 3 months ago and compare reinfection, you may get exactly the opposite result. Segregating by time is extremely useful here. But so too, or perhaps better, is segregating by antibody status.
I would like to give you one example of how this messiness in understanding the science is playing out. Over the past year we have heard that vaccination is safer than getting the infection previously. But in all those studies, and I think I can say all of them, they compared people who had the infection, at any time, to people who were just vaccinated. That to me seems unfair, based on the arguments above. However, just now there are new studies trying to correct this error. For example, the CDC reported matching individuals who had infection or vaccination and then reinfection, matched by time. Here, in a small group of 246 subjects, they were able to show that the unvaccinated group had an association of 2.34 times the odds of reinfection versus the vaccinated group. But again, what we do not know is the actual antibody levels of the individuals here. Nevertheless, it is a first step towards addressing this problem. Not far enough but a first step. It still does not give us answers. For example, the difference might have very little to do with the vaccination and more to do with the type of individual who did/did not get vaccinated, and other public health measures that they might or might not have taken. For example, I would venture that those who got vaccinated were more likely to take other public health measures, such as masking, social distance, washing, avoiding crowds, etc., than the unvaccinated. You see what I mean? This is why it was reported as an association rather than a causation. Knowing the antibody status would go a long way to clarify the situation.
Regarding time, though, we have to consider even this study, as placed within time, within an epidemic. In other words, lets attribute the full 100% effect of the difference odds ratio to the vaccine. Would that still be the case after another 2-3-4-6-10 months? The answer seems to be a resounding no. The effect of the difference shrinks over time. In other words, time, in all its relevance, should also be considered as a variable in any clinical trial, and any reporting, in the midst of an epidemic.
Time to talk, briefly, abut immunity and the immune system
I would like to speak, briefly about the philosophical argument against vaccinations in general. And here, I am not focusing on potential side effects, harm, etc. I want to focus on one specific aspect of the discussion. At this moment, 2021, the majority of vaccine outcome is related to the antibody response. Specifically, while we can look at the whole immune system as a coherent complex interrelated multi-mechanistic work of art, here, now, specifically, with vaccination, we are only trying to impact one part of the immune response, trying to get the antibody response, so that the antibodies fight the offending organism. When working at its most optimal ‘drug-like’ effect, we would have it targeting only the one bug, only in a very specific fashion, recognizing the bug before it goes into the cell, while at the cell wall and halting its ability to function. That is how it is supposed to work. Very targeted, very specific, and very effective, as long as the bug does not change too much, as long as the antibody does not target other things. There is a long list of ‘as long as’. But here I am trying to get to my main point.
There is another way to think of the immune system, back to the whole complex fashion of cascading interconnected components that when working together, may well impact the viral growth as well. Again, keeping this simple. There are many individuals, scientists, immunologists, physicians, that believe that focusing solely on an antibody solution is not going to get us over the goal line. That, perhaps, the solution might come from other parts of the immune response.
I want to discuss this briefly now, though more when we discuss natural therapies in the next post. Most specifically I want to focus on the CD4 and CD8 T cells which are part of the immune response that is able to recognize offending agents, has memory, from prior infections, and while slow to the fight, have a much broader range of influence than only antibodies. In other words, while the antibodies might be thought of (excuse the analogy) a single bullet flying quick and early, and highly precise, though accuracy is on or off, the T cells might be thought of as a shotgun spray in a general direction, slower, but covering a wider area, much less precise but perhaps more accurate, more of the time. And the interesting thing about these is that they seem to be of benefit not just in one version of the bug, but also as the bug mutates. T killer cells keep their ability to help even against a mutating agent. They keep their effect even against a related, but not the same germ. One of the benefits of these other aspects of the immune response is that they also make antibodies perform better. Anyway, there is a lot here, but I just wanted to give one example of another way to look at how to contend with the virus. Here is one article further delineating this topic. Perhaps the next iteration of vaccines will have this in mind.
Related, a question about natural immunity
A related topic now, the impact of natural immunity versus vaccination. One other philosophical argument against vaccination revolves around the concept that infections are not bad, in and of themselves, as they help train the immune system to better adapt to the environment. As above, the idea is that current vaccines only work by creating an antibody response, so only one part of the immune system develops, and if all goes perfectly well, without any problems, and only benefits, then the antibodies protect you well. Again, let’s just discuss the ideal here, so that I can share another point. Here, the rest of the immune system never gets trained, does not learn and does not grow to adapt to a wider environmental stress. It may be, that natural immunity, where the whole immune system grows and adapts is better able to protect you in the future to a large host of bugs. This does not happen with vaccinations, but may happen when the whole immune system meets and reacts to a germ. The argument here, is that having just an antibody response vaccine is not useful in the long run, and that only having an antibody response vaccine is a losing proposition, reasons some choose to sidestep the vaccine.
This argument is more refined and longer than this, but this is the considered point, from people who know a lot about this topic. I link to just one article that illustrates the point that I made last time that perhaps a combination of vaccine and natural exposure completed in a controlled and safe manner, would round out the immunity and may well be the best short term solution. We just have to figure out how to operationalize this in a safe manner. Here, the study demonstrates, that those people who had SARS-Cov-1 (or SARS), almost 2 decades ago, with a similar bug to COVID-19, seemed to have an excellent immune response to the SARS-CoV-2 vaccine almost 20 years later, even better, and more wide spread potential protection, to more variants, than those not exposed to SARS previously. In no way is this even remotely expected by the current vaccines. In other words, those people who got the natural infection years ago were better able to fend off other new related germs than those that did not have that exposure decades later.
All in all, the overarching topic is vaccines creating a selective evolutionary pressure, leading to the variants, and for these as well as other ‘benefit’ reasons, as well as potential ‘harm’ reasons, some do not want to get vaccinated.
Yes and No/Right and Wrong
In the next posts, I will address these points, and offer one path on how to proceed. Here I want to highlight a bit of the reality, on the ground. As I am writing this I have seen more pneumonia patients in one year than I have in 35 years of practice. My patients report family members dying at a disturbing rate. Many have lost people who were young and hearty. Hospitals are jammed in the ICU. Hospitals are again locally running out of oxygen supplies in the USA, refusing patients with pneumonia, even those with very poor oxygenation rates because there is no room for them. Labs/X-rays are not being performed because they do not want active COVID-19 patients in the hospital. Both Amy and are experiencing this on a daily basis with our patient population. We have seen it with our own eyes and heard with our own ears from patients who, nightly, say goodbye to their loved ones, because they do not know if they will still be able to take a breath in the morning. And I have not slept in a couple of days, trying to keep 2 people alive. There are true facts on the ground. Poorly reported, yes, and reported in a such a way that people that do not want to look at this do not have to, can skirt their responsibilities, but the facts on the ground are brutal.
My point is this. While all of the above is true, and while we need better solutions, what we also really need is a ‘time out,’ a way to buy ourselves some time to get it right. We know that these vaccines while not perfect, buy us that time. For the very vast majority of people, the protection these current vaccines offer will keep you out of the hospital, out of the ICU, off ventilators, and alive. The problem is that this seems to be the only solution focused on and that will wind up being a mistake.
There is another way to consider this, that related to classical biology, stress and strain and predisposition. You have to take each stress based on its relevance to our susceptibility. For whatever reason, when SARS-CoV-2 became known, its morbidity and mortality rates were just too high. We needed to, and still need to, buy ourselves time, to get a more permanent workable solutions in place. In other words, you can still maintain your concerns about the overall topic of vaccinations and where they should fit in the larger scheme of public health, still be concerned, worried and not like them, BUT still do this one, for now, to buy yourselves some time.
Isolation
I have been a great proponent of protecting yourself from those that are ill. My best example is that there are island states that have taken this to the maximum degree and as a consequence have hardly seen any COVID-19 patients. New Zealand, but even in the USA with Hawaii and US Virgin Islands, and Puerto Rico, having relatively few ill as examples. Isolation works. Isolation and frequent testing works. Testing frequently any suspected cases really works. But all of these are meant to be temporary solutions.
From the start we discussed the idea that this is a new germ that is not going to just go away. We have to learn how to live with it. Think of all of these solutions as temporary until we get a better one in place. While vaccinating is a good temporary solution, doing other things, to buy time, is only prudent. It is about impacting your odds or your chances of catching this now that you can control. While I believe that in the future morbidity and mortality will continue to drop, at this point you want to lower your likelihood of catching this bug in the first place, at least until we learn how to catch it is a safe way, without lasting problems, like we have with the common cold. Simply put, take care. You all know what to do if you do not want to get sick. We all know what we would do if someone had a horrible contagious disease. Same here. But think of it as temporary while we get to a more tenable, permanent solution. Just as these countries and states are developing new strategies on how to deal with the situation, you should as well. If you are in this group, of unvaccinated folks for now, protect yourself as best you can. But please be aware that this germ is here for the duration.
Our Children
As of today, COVID-19 vaccines are not supposed to be administered to those under 12 years of age. Tests are underway to extend the vaccination age to drop below 12 years old. I have a few comments here. First, I know that there are some physicians that are already vaccinating this population. While I understand the anxiety that might drive one to do this, this seems illegal to me. Also, it seems improper since we do not know the effect of the vaccine upon this group. That is what testing is for.
Related to the time variable mentioned above. I asked people to get vaccinated with the first shots, when they came out. I mentioned that I need your help especially for a large segment of my patient population, kids that were severely impacted by other vaccines, where the vaccine boards agree that this was the case. I wanted your help with them. By all of us getting vaccinated, early, we would have given our kids a much larger window before our vaccines wore off. With all of us being vaccinated, the likelihood of variants quickly developing would have dropped, the likelihood of schools being shut down as long as they were would be less, and all in all, our kids would have been in a better state. No more large outbreaks, no more clogged medical offices, hospitals. But that did not happen and now we are up against the natural inclination to extend the vaccine to this population. Therefore, this ‘halo’ effect around the children never materialized. To say that I am disappointed does not come close.
But before we rush into this, there is a very real question of do children need any vaccine for this in the first place? In general, we know that the very vast majority of people who contract SARS-CoV-2 have either an asymptomatic or mildly symptomatic version of the illness. In other words, things go mostly well for them. This we knew from the start. We also know that children in general are either more resistant to the virus, or when they contract it their percent of asymptomatic or mildly symptomatic is higher than adults. In other words, for the vast majority, they get through it well enough.
However, we also know some children have a severe form of this illness, some end up in the hospital, some end up in the ICU, some die. This is, relatively speaking, a small number but a very real one. And if you think about my comments above, about isolation, the virus will find suitable hosts, and as time progresses, it will impact kids more and more. This makes sense biologically speaking. We do not want this. Who would?
However, if you think about the other comments above, about the potential antibody dead end, and about how vaccines, as prepared today, are only focused on short term antibodies. And if you take into account the comment about the rest of the immune response, and the comment about natural immunity post catching the virus, being perhaps more useful in the long run, it puts into question whether kids are just small versions of ourselves, or if the as a subgroup might already be better off to build up immunity via natural infection, reinfection, over time. AGAIN, DO NOT DO THIS AT HOME. THIS IS JUST A DISCUSSION. DO NOT EXPOSE YOUR KIDS TO THE VIRUS ON PURPOSE. THE MEDICAL AND RESEARCH COMMUNITY WILL HAVE TO CREATE A PROCESS WHERE THIS CAN TAKE PLACE SAFELY. This part really needs to be studied, and solutions found. The only way we can do this is by testing children’s antibodies, daily, looking at immune status. We already know that there are MANY kids that have contracted COVI-19 but it was so mild that no one really took note. Test children, see what their antibody levels look like, see what the T killer cells level look like. Try to identify what is unique about the subgroup that develops a more serious version of the disease. Why did they, versus the other children fare that way? In other words, if we only look to vaccinations, then we can never really end at understanding what makes different kids more susceptible than others. If we can understand why some kids have a lower susceptibility than other kids, it might help us understand how to make adults have a lower severity of the illness as well. Unless we can engage in this level of discourse, then the conversation remains at vaccinate or not, which stifles science and progress.
There is a lot more here, as to how things could have gone, as to how things are now, as what could be done now. But the bottom line, for those that have not been vaccinated, is try to buy yourself time. Obviously, I thought you should get vaccinated with the first shot months ago, but if you are not, and if you cannot because of your health status, history, economic reality, age, etc., then the main thing you have to do is buy yourself some time, until the science gets better sorted out by identifying the subpopulations. Delay, delay, delay. Which for me starts with going back to public health measures, wear your mask, filtering the air around you, wash your hands, limit exposure to groups of people, and the advent of better and repeated, complete, quantifiable testing.
What needs to happen NOW
We have enough time now, starting today, to learn how to get ourselves out of this bind. For the people that have not been vaccinated consider the following:
1. Get a QUANTITATIVE antibody tests for the SARS-CoV-2 wild type virus. This will show you where you actually stand vis-a-vis the virus. In the race to the path of vaccines, we as a society, deemphasized testing. This has to change. Routine quantitative testing for antibodies, should be an important part of a broad sweeping public health plan. This is true if you caught COVID-19. However, since we know that many people experience an asymptomatic COVID-19 phenotype, it may be that you caught COVID-19 unknowingly. Therefore, everyone get tested for the antibodies, just to see where you stand. Also, this will help science understand a more complete picture of this virus impact on us.
2. If your antibodies are present, you probably had COVID-19 before, knowingly or unknowingly. If your antibodies are high, then you might be able to wait for science to catch up. (OBVIOUSLY, YOU SHOULD DISCUSS THIS WITH YOUR CAREGIVER, AND CONSIDER YOUR OVERALL HEALTH AND IMMUNE STATUS AND ANY UNDERLYING CHRONIC CONDITION WHICH WOULD IMPACT YOUR HEALTH CARE DECISION.)
3. If the antibodies are completely missing, you may be in the same exact category as those that were never vaccinated AND/OR those that caught COVID-19 a long time ago and no longer have the antibodies. In other words, even though you may have caught COVID-19 in the past you may at this point be as susceptible as those that did not. Take proper precautions.
4. For those that have some, but not enough antibodies, you are at a certain level or risk. Consider getting the vaccine, if available. As mentioned before, those that had had COVID-19 before, and take the vaccine have a higher rate of antibodies and seem to have a wider level of protection, at least for the short/medium term. More on this in the next posts. However, it might be that what will be proposed, in the future, is allowing people with some of the antibodies to the virus to catch the virus anew, during this period of time, to let them build an overall immune response. How to operationalize this in a safe, scalable manner is the challenge and to my knowledge, is not yet being explored. This is where clinical and research science needs to step in. We need those that have resources to do this work. It is a clear change in the path and it makes obsolete arguments that currently exist. Path changes do not happen out of the blue. There needs to be sound theory behind them and I am sharing that here, in short form. I would absolutely love to be part of this game change. I AM NOT SUGGESTING YOU DO THIS ON PURPOSE NOW, BUT IT IS MY HOPE THAT THIS PATH WILL BE THOROUGHLY INVESTIGATED IN THE NEAR FUTURE. We already are investigating severity of reinfections.
5. As you know, I believe that, UNTIL WE GET OUR ACT TOGETHER, you should strongly consider getting the vaccine, though hopefully soon a version modified for the current strain. Vaccination is neither the complete solution, nor even a great one, and is not going to be the end of the story, but hopefully, it buys a year, until science can catch up. I hope we do not waste that time.
6. In all respects, the vaccine manufacturers should conform the vaccine development to change the vaccine to match the current variant so that there is more optimal antibody formation. This again would buy another set of months to allow science to perhaps develop to a more reasonable, multi-pronged, effective and long-lasting solution.
7. As highlighted for over a year, until we test everyone, there is an inexpensive manner to diminish viral and other microbe exposure in your environment by adding filtering systems to your surroundings. I have described previously how to build one in an inexpensive manner. This may cut down transmission rates as well. Regarding this filter. I want to highlight this here, today. Consider the reality on the ground, a parent has COVID-19 and their children are being exposed to them. Or one child has it but the siblings do not yet have it. It could be that this is unavoidable in this household. It seems almost criminal to not tell your patients about this and to add additional ventilation that is affordable and that might cut down the overall viral exposure. Just do it. This is a very easy, specific thing you can do now. Please consider doing this.
8. Take all public health measures.
9. There are a number of other therapies you might also consider, if you cannot take the vaccine. None proven beyond a shadow of a doubt, but all having some level of validity. I discuss these in my next post.
I asked for help 8 months ago, in this respect, and said that if we do not change the discourse, all we do is waste the precious time the first set of vaccines offer. That over time, unless we take correct action, vaccines will become mandated. We are well on our way to having squandered that time. But there is enough time left, even now, to change this path. I hope that we take this work up in earnest or else the path continues as it is. Boosters will be offered, and if not fantastically effective, the public health program fails, and then we are in a real mess.
And regardless, it really is time to take up the concept I suggested from the start as the main tool, of developing testing to see if you have COVID-19 or not, (with quantitative measures, that are inexpensive, easy to administer, and accurate), whether you are vaccinated or not. If you test negative, you go about your normal, pre-pandemic life, and if you are positive, you quarantine until safe. This remains one of the quickest ways to get us out of this mess. Rates drop. Transmission drops. Latent subclasses are exposed. And better science can occur. This should be front and center as the main new development in science. It is not hard. We only have to demand it. One very clear action you can take is ask your clinician for this. They will most often say that it is not available. And then ask your clinician to put requests/complaints in to their medical societies. Likewise, with your government representatives. Eventually, that message will be heard.
I want to end on the same bright note as before. These sorts of epidemics always start the same way with the highest rates of mortality and then settle down. As long as you are still alive, still not dealing with chronic ailments from the virus, you are buying time to let the epidemic calm down. Over time, as it enters an endemic state the mortality rate will continue to drop. Overall, in the big picture, each local flare-up should be smaller than the prior flare-up, locally speaking, as described more fully above. It is just getting you from here to there that is paramount!
