Nationally, cases and deaths continue to rise, though at a lower rate than 2 weeks ago.  Connecticut ranks as the 17th state from the top of the list of cases per 100,000 persons.  In comparison, Rhode Island is at the 4th place, New York in the 9th place, and Massachusetts  is in 10th place.

In Connecticut , Windham and New London counties top that list, at 95 and 93 cases per 100,000 persons, while the other counties are in the 50’s to the 70’s.

Now that vaccination has been introduced world-wide we are starting to see more data on adverse events.   But before addressing what has recently come out in scientific and news reports, I would like to set the stage:

  • The first dictum for an individual physician is “Primum non nocere”, a Latin phrase which means “first do no harm.” An individual physician deals with individual patients, one at a time.  In the sphere of public health, however, medical science deals with populations as a whole.  Large populations can of course be divided into smaller units such children, young adults, middle-aged, the elderly, those with or without various chronic diseases like diabetes, heart disease, autoimmune disease, allergies, etc.  But still those subunits are composed of people who may differ in many other categories of health, to say nothing of their race, their stress levels, their socioeconomic status, their histories as groups, etc.  These differences, in various combinations and permutations may become significant when individuals have to make choices and seek guidance from their doctors.  When the science is not adequately settled, the situation becomes much more complicated.
  • In the present situation, the question of vaccination is clouded by all of the above factors. Those who deny the existence of the pandemic have no basis in fact for that view.  As I have previously discussed, pandemics are part of human history, and will continue to occur.  COVID-19 is the 3rd major epidemic from the family of Coronaviruses.  The first was SARS (Severe Acute Respiratory Syndrome) which began in 2003.  The second was MERS (Middle East Respiratory Syndrome)in 2012.  Those two were lethal enough that their spread was easily contained, since people got sick and died quickly.  COVID-19 is much less lethal and much more easily transmitted and as a result has spread globally.
  • I have previously noted the failures of many governments to limit the spread of the virus. I have also noted that even in countries which did well (China belatedly but then efficiently), South Korea, and New Zealand most notably, 2nd waves are occurring at higher levels than the first wave.

So here we are a few weeks after the introduction of the mRNA vaccines from Pfizer and Moderna.  Allergic reactions can be severe, although rarely, and can result in death, even more rarely.  A Florida physician in good health developed a fatal autoimmune blood disorder on day 3 after the vaccination and died.

In Norway, the government has revised its guidance to physicians who treat the elderly based on a number of deaths soon after vaccination in already frail persons aged 85 and older.  Assuming that vaccination and those deaths are related, this is obviously a “harm”.  But these people would presumably have died of COVID-19 had they been both unprotected and exposed.  How can an individual physician distinguish which of the many very elderly and frail people in nursing homes (high-risk environments) might not be able to tolerate the vaccine?  That this intolerance would exist was never in doubt, and such deaths were “expected.”

In Israel, as reported in the Jerusalem Post 13 cases of Bell’s palsy occurred after vaccination.  Most people recover completely from an acute Bell’s palsy (one-sided facial paralysis), while a few will be left with some residual paralysis.  Assuming firstly that the reported cases of paralysis are firmly linked to the vaccine, would the outcome for those particular patients have been worse if they were both unprotected and exposed?

In the development of previous coronavirus vaccines (SARS and MERS)  enhanced immune system reactivity to other infections, such as influenza, was found.  This includes enhanced reactions (stronger symptoms that might otherwise have occurred) to other coronaviruses, some of which have long been known to “cause” some common colds.  I put quotes around the word “cause” because illness is often as much or more about susceptibility to a noxious stimulus (bacteria or virus, toxins, etc.) than to the presence of that noxious stimulus.  Of course, when a virus is introduced to a population that has had no previous exposure to it, as is currently the case with COVID-19, the results can be severe, as evidence by the reaction of Native Americans to exposure to smallpox and measles when the Americas were colonized by Europeans.

The last item of news for this post is the introduction of a newer vaccine (Novavax) which is now in production.  While this is also a “spike protein” vaccine, it is formulated in an entirely different way from the Pfizer and Moderna vaccines.  The “spike protein” which is used by COVID-19 to attach to human cells (establishing the infection) is composed of 2 “subunits” named S1 and S2.  While the Pfizer and Moderna vaccines are aimed at S2, the Novavax product is aimed at S1.  Since S1 is the subunit that the spike protein uses to attach to the cells, the Novavax product may actually reduce the risk of infection, as noted in the early investigations of the vaccine conducted in monkeys.  S2 has to do with the virus’s entry into the cell after attachment so that it can multiply inside the cell.  We do not yet know if the Pfizer or Moderna vaccines actually reduce the likelihood of infection or spread.  The effectiveness of those vaccines appears to be that people don’t get sick, with an impressive protection rate of 95%.  But we know already that asymptomatic people spread the disease.  This is why recipients of those vaccines are still going to have to wear masks and practice social distancing.  Whether they will choose to do so is unknown.  Please note:  one can be infected but not sick (asymptomatic), and spread the virus to others.

While I am neither an immunologist nor a virologist, if the Novavax vaccine proves to be effective and safe, it might be a better choice than the currently available vaccines.  But the Phase III trial has just begun and early results will not be available until March 31st 2021, and the trial will not be concluded until December 30th 2022.  We also do not presently  know if the vaccine will pass scrutiny and be authorized for Emergency Use Authorization.  The Phase III trials for the Pfizer and Moderna vaccines have both reported their preliminary results and have gained Emergency Use Authorization from the FDA,  but the final reports will also not be issued until the end of 2022.  That means that these trials are still in process.

There are also many other vaccines in development.   It is more traditional for vaccines to not be licensed until Phase III trials are complete and have undergone scientific and regulatory review.   As a society however, we find ourselves in a crisis situation, which might have been avoided had world reacted more quickly or had been better prepared when this all started in the fall of 2019.

Getting back to “first do no harm”, my duty is to inform my patients to the best of my ability.   Even though we don’t yet have all the information that would make for a fully-informed choice, when vaccines are available, choice is unavoidable.  The choices:  vaccinate now; wait for more data or other vaccines; or never vaccinate. All choices contain potential risks and benefits.    We should all understand that those risks and benefits pertain both to ourselves and to our family members, to our friends and people that we come in contact with, and to society as a whole.   To not vaccinate ourselves eliminates possible risks from the vaccines (which so far have for the most part been “tolerable” from a public health standpoint) but also exposes us to infection and sickness from the virus.  This then creates the possibility of spreading the virus to other people who may then suffer a disease which can be asymptomatic (but spreadable), or result in a mild illness, or a more serious one that can later lead to significant disability or even to death.

In America, individual rights are strongly emphasized.  The pandemic has exposed us to the consequences of not sufficiently taking the collective interest into account.

Finally, as of the week ending on January 9th, the CDC reports continuing “unusually low” levels of flu activity.