COVID-19 Column of September 2021

A- The FDA (Food and Drug Administration) has authorized a third dose of the Pfizer-BioNTech COVID-19 Vaccine and the Moderna COVID-19 Vaccine to certain immunocompromised individuals. A third dose can be also administered at least 28 days following the Pfizer-BioNTech COVID-19 2 doses is also authorized for individuals at least 12 years old who have undergone a solid organ transplantation. The same authorization has been given to the Moderna COVID-19 vaccine for individuals at least 18 years old who have undergone a solid organ transplantation’

This third dose seems to be effective in increasing antibody titers. Further recommendations can be expected by the CDC Advisory committee on immunizations for individuals on the way to proceed. The delta variant of the virus is imposing its way with a new wave in the COVID-19 pandemic. Other fully vaccinated are adequately protected and do not need any additional dose of COVID-19 vaccine.

B- A new Israeli study fuels debate on Vaccination and Natural Immunity in COVID-19. More than 700,000 Israelis were compared to 3 groups. The first group has not been infected but has received the 2 doses oyf vaccines, the second group was formed with infected individuals completely unvaccinated and a third group in which individual were infected and received one dose of vaccination. The researchers found out that uninfected vaccine recipients were 13 times more likely to experience a breakthrough infection than those who were previously infected. It is a proof that natural immunity is better than vaccination.

C- New vaccines mandates were announced by universities and large companies after the FDA approval of the Pfizer’s COVID-19 vaccine. Vaccinations will now occur within the military. A careful approval process may increase people’s confidence in the vaccine as well. We know the way the process was rushed because a typical vaccine takes between eight to 12 months prior to approval. Pfizer’s vaccine was approved in 3 months.

D- In Florida, mask mandate has been imposed on student in pre-kindergarten through 8 th grade defying the government. High school students are old enough to get vaccinated. In some counties, Positive COVID-19 tests are increasing since school started in August. In a district, 245 cases and 900 students were placed in quarantine. The governor threatens to cut funding to district observing mask mandate against the government will. Schools are filing law suit to challenge the governor. Many counties like pam Beach, Hillsborough, Miami-Dade, Broward, Tampa, St Petersburg Gainesville etc plan to have a mask mandate. Mississippi hospitals, especially a level 1 trauma announced Friday that all staff and students will be require to get vaccinated. Employees have also the choice to wear N-95 mask if they refuse vaccination. As students heading back to the school this fall, many cities and states are implementing as well new requirements on teachers to get vaccinated.

E- The CDC recommends to the high-risk groups to avoid any cruise ships like pregnant women, elderly and people with underlying conditions. People with weakened immune system. Be sure also to wear the masks and practice social distancing. The virus spreads easily between people in close quarters aboard ships and outbreaks have been reported on ships. More passengers should be tested prior to boarding and soon after the cruise regardless the status of vaccination. If not tested after the cruise, passengers who travelled should self-quarantine for ten days as stated by the CDC.

F- Worldwide there are more than 4.43 million deaths and more than 212.19 million infected cases. In the United States there are more than 37.78 million cases of COVID-19 and more than 628, 760 deaths.

G- Nobody knows the long-term consequences of post vaccine myocarditis. It is believed that 5 to 25% of patients hospitalized with the disease will develop some evidence of myocardial injury. This may pose a high risk in a competitive athlete, knowing well that myocarditis is a top cause of sudden death. Most of universities require now comprehensive testing for student athletes in most of the big universities before allowing them to play after COVID-19 infection. A prevalence of 2.3% was found in a study for myocarditis after cases were found following cardiac magnetic resonance imaging (CMR). This modality has allowed to a have a 7.4-fold increase in the detention of myocarditis cases. Myocarditis has been seen also after mRNA vaccines COVID-19 by Pfizer and Moderna, in male adolescent and has been seen after the second dose. In collegiate students’ athletes who tested positive for the COVID-19, 15% were found to have signs of myocarditis. On CMR, myocarditis was consistent and other tests like EKG and Troponin levels were found normal. Such athletes were either asymptomatic or mildly symptomatic. What is the significance? It is hard to know because 30.8 % of the athletes have also exhibits gadolinium enhancement (LGE) without T2 elevation, being suggestive of prior Myocardial Infarction. We still do not know the long-term consequences of myocarditis in this population.

H- Myocarditis is certainly a top cause of sudden death in the competitive athlete. We have already reported in a previous AMHE Newsletter a prevalence of 2.3%reported in JAMA Cardiology May 2021 from CMRI (Cardiac Resonance Imaging Resonance). More, myocarditis detected 4 days after the second dose of COVID-19 mRNA vaccine. They found 323 persons with vaccine-induced myocarditis and 309 were admitted to the ICU for monitoring. 295 were discharged. There was a preponderance male.

I- Scientists believe that the “Fatality rate” has dropped from April to December perhaps because of improvement in diagnosing or treating but unfortunately the death rate has quadrupled. COVID-19 is much deadlier than the flu and we should invest more in the prevention and treatment of COVID-19.

J-  The WHO has used Greek letters because the letters are short and easier to remember. Delta variant is easier than B.1.617.2 and avoid stigmatizing the place where the variant comes from… like the Indian variant etc. They are used to design contagious or virulent variants. Epsilon, Zeta and Theta were also low-grade variants down-graded. The alphabet has 24 letters and if there are more variants, the WHO will have to choose another way to call the offending variant. The Greek alphabet derives from the      Semitic alphabet of the Phoenicians and even have some Hebrew words. Other alphabets may enter in paly like the English alphabet or the Cyrillic alphabet in Central Asia etc.

L- Nature magazine has revealed that the virus of COVID-19 has infected more than 1/3 of the American population. The administration is ready to proceed with an additional booster shot which is already available with the Pfizer-Bio-N-tech vaccine but will take time to be on the market for the Moderna vaccine. More the USA had the highest number of confirmed COVID-19 cases in 2020, surely because of our capability to perform the test and more deaths in the world.

M- Half of the people with the COVID-19 who were hospitalized have suffered of persistent symptoms a year after their discharge. Symptoms like fatigue, muscle weakness are common findings. Often, they may also experience more shortening of breath. Others may experience anxiety, depression. Long haul COVID-19 is a medical challenge and many symptoms will resolve with time.

N- The European Union has recommended to its 27 member nations to stop receiving non-essential travelers from the United States of America and other countries that have reported spikes in COVID-19 cases. Although the most popular variant in the Delta in the USA, but in 49 states the “MU” variant has been discovered recently and time will dictate its virulence.

O- Can anybody get the Flu and COVID-19 at the same time? When a morning, you wake up with temperature elevation and feel a little groggy. Indeed, it is possible to get infected with both. It can start with the basic flu and eventually affect the lung, kidneys, liver and brain. The virus is contacted nearby an infected person who sends droplets into the air by coughing, sneezing or even talking within the 6 feet range around you. The infected person may not feel sick but may infect you even after you touch an object on which he/she placed the virus. Once the virus enters the body, it settles in the cells in the nose, the sinus cavity and the throat. It will take up to two weeks for the virus to invade the healthy cells.

Symptoms like fever, headache, sore throat and dry cough will settle and you may develop shortness of breath, loss of sense of smell or taste, fatigue, runny nose, nausea or diarrhea. If the immune system can’t handle the virus, the virus will reach the lower respiratory system and the lungs. Fluids and mucus build up and render the oxygenation harder, settling with pneumonia. Many will recover in one week to two, others will take longer. The pneumonia may worsen quickly damaging the lungs damaging the alveoli which become filled with gunk. Radiographic studies (X-Rays or CT-Scans) will show a restriction in the air exchange forcing a drop in the Oxygen levels. The lower the Oxygen reaches, the more it will be a need for a respirator/ventilator to help in the breathing.

Our intensivists think that the immune system become unable to react and more serious complications of COVID-19 will set up. High level of cytokines that immune cells start to attack healthy tissues developing at time a cytokine storm and leading to high blood pressure, multiple organ failure and blood vessel damage.

Organs like the heart in a seriously ill patient with COVID-19 will develop Arrythmia, Cardiomyopathy, Acute cardia injury and shock. The blood vessels may develop blood clots leading to strokes or pulmonary embolisms. Such patients will develop a substance called “D-dimer” in the blood stream, precipitating more blood clots. The disease appears to attack also the nervous system stimulating seizures, loss of consciousness, loss of smell and stroke. Half of hospitalized people with the disease present an elevation in the liver enzymes. A third of patients will develop conjunctivitis. Other in the intensive care units, seriously ill, will definitely show as well kidney damage. 40% may remain asymptomatic but with radiographic studies still showing lung damage including what we call “ground-glass opacities”.

P- In conclusion, Yes …Yes … Yes …two invaders at the same time COVID-19 and the Common Flu can exist together and this may be the fear for the healthcare professionals because fighting of both viruses at the same time may be catastrophic for the immune system. It is difficult for the immune system to fight Influenza and COVID-19 in producing enough antibodies to neutralize each virus.

It is recommended to get the Flu shot as well than the COVID-19 vaccine and off course continue the habitual precautions in wearing masks in public and observing distancing in staying away from others, wash your hands frequently.

Maxime Coles MD

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