Paper and Threads

I read two pandemic papers several weeks ago that made me very sad.  While we've all been alarmed at the number of deaths due to Covid-19 these two studies focused on the number of (1)  children who lost a parent and (2) deaths of health care workers.  I don't understand the modeling methods used in the first study, but it is published as a detailed research letter in JAMA Pediatrics, a reputable medical journal. They say that sudden parental death can be particularly traumatizing to children.  Their model demonstrates that from February 2020 to February 2021 there were 37,300 children aged 0-17 who lost at least one parent (9863 less than 9 years old).  Approximately 75% are non-Hispanic whites, the remainder non-Hispanic blacks.  We can only guess the types of trauma this causes in children and the support that will be needed for them.  I remember one family presented on MSNBC by Nicole Wallace in which both parents died, several days apart, leaving multiple young children.  See Below for Study on Health Care Workers

Information about health care workers appeared in the Guardian based on data collected from mid-March 2020 to April 7, 2021.  More than 3600 health care workers died with 50% of them being less than 60 years.  A majority of deceased workers were people of color and more than a third were born out of the US.  A huge number of deaths occurred early in the pandemic, probably in part related to the difficulty getting PPE.  Most of the deaths were nurses and support staff, but also included physicians, pharmacists, first responders and hospital technicians.  Only about 25% of the people who died worked in hospitals.  Other people who died worked in places like residential facilities, outpatient clinics, hospices, and prisons etc.  Covid-19 is a deadly infection and I admire the physicians, nurses, respiratory therapists and other personnel so much. Since then scientists have developed very effective and safe vaccines and this is my plea to everyone reading this to please get vaccinated.  Dr. Michael Osterholm told everyone listening to his podcast from Thursday to get 2 people to agree to getting vaccinated. Please....

Posted by Shirley at 6:19 AM | Permalink | Comments (1)

The J and J PAUSE is over after more vaccination data was collected, analyzed, and discussed at length at the CDC-ACIP meeting on April 23rd.  These clots are now called thrombosis with thrombocytopenia syndrome (TTS) and there are now a total of 15 well studied cases which means that this is a very rare adverse effect of the vaccine.  All of the cases were in women (13 in 18-49 years of age and 2 who were 50+).  Cerebral venous sinus thrombosis (CVST) occurred in 12 of the patients, the others had other large vein clots.  Nearly 8 million people were vaccinated with the J and J vaccine since it was approved making the risk of TTS 0.7-1.6 cases/million vaccinations.  There was a significant discussion of the benefit of the vaccine vs the risk and the ACIP independent advisory board of scientists then voted to lift the PAUSE.  Having an effective vaccine that only requires one dose and no special storage requirements means that many groups of people that are house bound, in shelters, in jails, or in rural areas or other countries will be able to be vaccinated.  

The types of clots that occurred after the vaccine occurs in other situations.  Patients who develop Covid-19 actually have a higher risk of developing the clots.  There is also a substantial risk of the same clots without either the vaccine or Covid-19:   

     CVST with Covid-19     5-6 cases/million 

     CVST 2 weeks after Covid-19 diagnosis  39 cases/million (hospitalized patients)

     CVST without known associated trigger  14.5-28.5/million US population per year   See Below

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The committee recommended that a Warning be added to the Vaccine Information.  Women who are 18-49 years old can elect to get one of the mRNA vaccines to reduce their risk.  Physicians will be provided with formation to make a prompt diagnosis when patients develop a severe headache, abdominal or leg pain, or shortness of breath.  A platelet count should be obtained and if <150,000 immediate treatment with intravenous IgG and a non-heparin anticoagulant should be started.  The diagnosis should be confirmed with a PF4 antibody assay, but treatment should begin before the results are obtained.  Physicians also need to be cautioned that patients should not be given heparin  or platelets This newly described clotting process appears to be an immune response to the vaccine and resembles a rare clotting disorder that occurs in patients being treated with heparin.  No other underlying risk factors were identified among the cases.   

Posted by Shirley at 6:28 AM | Permalink | Comments (0)

I have a guest contributor today - my son Jason - who is a Pediatric Hematologist-Oncologist.  He has a daily Instagram post with family photos of the day (for us I hope - to see our 2 grandchildren) and a paragraph about the pandemic.  This was his science paragraph from yesterday.

"A terrific study was published today in Nature (one of the pre-eminent scientific research journals) that details the very health care issues faced by people who get even mild cases of COVID.  The study looked at non-hospitalized VA patients, comparing over 73,000 who were diagnosed with COVID to nearly 5 million who were seen for non-COVID reasons.  And the top line result is that in the 6 months following their diagnoses. the COVID patients had an increased risk of death, respiratory disease and failure, clotting disorders, neurocognitive disorders, diabetes and hypertension, among a number of other conditions.  In addition, those who had COVID used more pain medications (both opioid and non-opioid), antidepressants, and cardiac medications.  More Below

All in all, it is sobering, because it is a real-world look at what people might face if they get COVID (even mild or asymptomatic).  And it is a massive wake-up call about the importance of doing everything we can do to avoid getting COVID - mild or severe, there's a very real chance that you'll spend months or more dealing with the consequences.  So keep wearing your mask around others and indoors, get vaccinated, and help those in your life make good choices and get their vaccine appointments.  We can do this! "

Posted by Shirley at 11:54 AM | Permalink | Comments (0)

We know the efficacy of the mRNA Vaccines from Phase 3 trials, and now we can look at Breakthrough Cases to assess "real world" effectiveness.  A breakthrough case is defined as a Covid-19 positive patient who developed Covid-19 more than 2 weeks after their 2nd vaccine dose or single dose of J and J vaccine.  This week the CDC published data on 5,814 breakthrough cases  collected from Dec. 14 - April 13.  These infections are expected to occur because no vaccine is 100% effective.  But in science it is always important to know the denominator!    As of April 13th 75 million people were vaccinated in the US, but how many of them had 2 doses and were more than 2 weeks out from their final dose.  The CDC relies on State reporting systems for breakthrough cases and only 43 States reported cases.  Of the cases reported, we don't know how many  of them had a sample for genomic sequencing for variants.  The data is probably underestimated and not helping to determine true incidence and protection against variants due to incomplete reporting and lack of original samples to identify variants that are spreading.

The cases were from 43 States, 45% were 6O years or older, 65% were women, and 34% were asymptomatic making it hard to know how the cases were even identified.  Three hundred and ninety-six patients were hospitalized, and 74 died.  From now on the CDC will modify their "breakthrough case" surveillance to those patients who are hospitalized or die - in order to get the most important information.  See Below  

Another recent report to illustrate the value of the denominator: 6 women who received the J and J vaccine, 6-13 days before, developed CVST (cerebral vein sinus thrombosis) with thrombocytopenia (low platelets).  One patient died and only 2 already left the hospital.  All of the patients had a positive platelet factor 4 (PF4) test to detect the autoantibody that may be causing these clots/low platelets.  Approximately 6.8 million doses of J and J vaccine had been administered to date in the US (risk 1:1 million).  But is the denominator really 6,800,000 or half that to determine the risks in those vaccinated within the month before the diagnosis of the clots, or only in the women vaccinated during that time period?  Each time we decrease the denominator the risk increases. Then to confuse the science even more, there is also a risk of CVST in Covid-19 patients because CVST occurs in unvaccinated Covid-19 patients as well.  Will the Risk vs Benefit ratio of the J and J vaccine be enough to continue using it?  The CDC ACIP Committee will meet again on Friday.

Posted by Shirley at 6:14 AM | Permalink | Comments (0)

Evaluating a Headache After Vaccination with J and J and AstraZeneca Vaccines:  The rare clotting adverse event after vaccination with one of the two adenovirus viral vaccine vaccines is now being called vaccine-induced thrombotic thrombocytopenia (VITT).  I am a retired hematologist and have evaluated many patients with blood clots - venous and arterial - and in general the development of a cerebral venous sinus thrombosis (CVST) in very rare.  But the US Vaccine Adverse Effect Reporting System (VAERS) for monitoring vaccine safety demonstrated 6 cases, all associated with low platelets. This combination resembles a heparin side effect known as Heparin-Induced Thrombocytopenia (HIT) - in which patients on heparin develop antibodies to a complex known as heparin-PF4 (platelet factor 4).  I spent the first 15-20 years, after my training, in a lab purifying, characterizing, and then measuring PF4. Since then a test has been developed to measure the heparin-PF4 antibodies in patients with HIT.  Now these tests are found to also be positive in patients with VITT following the J and J and AstraZeneca vaccines, even though none received heparin 

Some Risk Factors for any Clots: OCP, pregnancy, malignancy, smoking, immobility, inherited disorders.  

Risk Factors for CVST: J and J Vaccine: 1 per million;  Covid-19 4-20 per 100,000; pregnancy 10-20 per 100,000 deliveries; oral contraceptives 2.7-40 per 100,000 people, and General Population: 3-15 per million per year.

The risk factors and incidence for development of CVST shows that the incidence for VITT is substantially less than the incidence in patients with Covid-19.  With the current data, the risk vs benefit ratio warrants continuation of J and J vaccinations, maybe to select age groups.  

The CDC-FDA still have a PAUSE on J and J vaccinations - to carefully study any patients that may develop clots within 3 weeks after their vaccination that was before the pause.  Patients who develop severe headaches, abdominal pain, leg pain or shortness of breath should see a physician and have an evaluation - including a platelet count and a PF4 antibody test.  Under no circumstances should patients with clot, low platelets, and a positive PF4 test be treated with heparin - instead consult a hematologist for alternate treatments.   

Posted by Shirley at 6:31 AM | Permalink | Comments (0)