COVID Transmissions for 4-26-2021
A surge in India; J&J vaccine resumed
Greetings from an undisclosed location in my apartment. Welcome to COVID Transmissions.
It has been 525 days since the first documented human case of COVID-19. This is an exciting one, because the year 525 was invented in 525. This isn’t trivial; in 525 the “anno domini” year-counting system was invented. Every year before that was not numbered the way we number it today.
Speaking of milestones, I feel like pre-vaccination vs post-vaccination is a big one, and I’m now vaccinated.
Today we’ll talk about vaccine safety events and also about the worsening situation in India.
First, though, I want to describe my vaccine experience. I have been offline on this newsletter since I got my second dose of the Pfizer vaccine. This is because my side effects from that vaccine were indeed a bit worse the second time around. The first dose left me sore and with some fatigue for a few hours the next day. The second dose I was a bit more sore and had fatigue for about 25 hours. At the end of the 25 hours, it switched off like a light and I felt like I’d woken up from a nap. But, I had a lot of catching up on work and other tasks to do as a result of the downtime, and took another day off from COVID Transmissions to get everything in order. Now I’m back, and in a short time—just until 2 weeks—I will be very likely immune to COVID-19 and its worst outcomes. Also, I got a sticker:
I’d like to find someone with a button press so I can turn the sticker into a permanent button, instead of something ephemeral that will go away.
As usual, bolded terms are linked to the running newsletter glossary.
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Now, let’s talk COVID.
The COVID-19 situation in India is even worse than last issue, when I said it was “very bad”
In the days since the last issue I wrote, the COVID-19 situation in India has worsened to where the country is now setting world records for daily new cases. Obviously this is terrible, and like I mentioned before, this is probably being distorted by underreporting and difficulties with surveillance.
COVID-19 is now overwhelming hospitals in India. India is a complicated place in terms of human development. There have been amazing efforts to update the country’s infrastructure and advance its economy, which have made tremendous strides. At the same time, there are many areas with serious human development issues in terms of basic sanitation and healthcare, with rural areas particularly lacking access to key services. There is also a lot of poverty throughout the country, both in urban and rural settings.
That’s not to say that the US doesn’t have impoverished areas or problems with delivery of basic services to rural areas, but the US also happens to be the wealthiest country ever to have existed and isn’t home to over a billion people, so comparing the two is a little bit difficult—the US is playing with a deck stacked tremendously in its favor.
The reason I draw this comparison is not just because I live in the US and I am thinking about India, though. It is because the US and India are now the two countries in the world that have experienced the highest absolute COVID-19 burdens. This is a grim club to be a part of, and we need to understand what lessons can be taken from the US experience that might help inform what is about to happen in India.
My deep concern with India for the moment is that their healthcare system cannot bear the burden that this is imposing, and we are already hearing reports of that. However, over the weekend I did hear about this one glimmer of hope—the US is sending aid, recognizing that it and India are in the unique club that I mentioned before: https://www.npr.org/2021/04/25/990676453/u-s-pledges-medical-aid-to-india-where-covid-19-is-overwhelming-hospitals
I hope that it helps prevent some of the deaths that are coming.
Myocarditis in young men with the Pfizer vaccine?
Someone asked me for my thoughts on this: https://www.jpost.com/health-science/covid-19-israel-finds-possible-link-between-vaccine-myocarditis-cases-666237
Specifically, Israel’s Ministry of Health has said they are investigating some cases of myocarditis—inflammation of the heart muscle—in men under 30 who received the Pfizer vaccine. Apparently, myocarditis occurred in 1 in 100,000 people who received the vaccine.
This initially sounds scary, but let’s defang it with a few facts:
Myocarditis is already most common in people under age 40
Annual myocarditis incidence is estimated at around 22 in 100,000
No other country has reported suspect myocarditis cases and Pfizer has made a statement that their monitoring has found no signals that exceed background incidence
I think that at least at first glance here, it’s very plausible that these are just the expected cases of myocarditis that one would see in any large group of people. In fact, with more than a quarter of the year past now, you would expect to see perhaps more cases of myocarditis per 100,000 by now, maybe 5 or 6 even. To see only 1 per 100,000 in the vaccinated group is lower than expectations. This may be due to the fact that myocarditis is often caused by infection, and people have been isolating from one another as part of pandemic control measures.
I don’t think there is a vaccine adverse reaction here. I think this is just people who got myocarditis. However, I don’t have a panopticon into Israeli health the way that the Ministry of Health there does, so I am glad they are doing some due diligence to investigate further.
Still, I’m really not concerned about this as a meaningful signal, unless we get new information.
Johnson and Johnson vaccination to resume in US with a warning in label
I watched last week’s ACIP meeting so you don’t have to. Here is a summary:
In consultation with the FDA, a warning was added to the vaccine label about the extremely rare clotting event, now that new data have become available. The number of cases increased to 15 in 7 million, so offering a risk around 1 in 500,000, which is very remote.
Also, the issue where heparin was being used to treat this syndrome has ended. Presumably because of the announcement of the pause and messaging about the issue, none of the cases that happened after the pause were patients who received heparin. So in that respect, the pause was a messaging success.
In light of the change to the label, ACIP voted to recommend resuming vaccinations with this product, since the adverse reaction observed is extremely rare and there is now good information on possible ways to treat it.
If I were not already vaccinated, I would feel comfortable going and getting this vaccine. If I were a female under 50, however, I would be watchful for any of the symptoms of CVST after vaccination—partly because these are also potential symptoms of other strokes that people might get for other reasons, and while strokes are rare, it’s important to treat them quickly.
This link has a rundown of what to look for as well as other information: https://www.hopkinsmedicine.org/health/conditions-and-diseases/cerebral-venous-sinus-thrombosis
The thing about the J&J vaccination at this point, though, is that it’s not really central to the US strategy: https://www.politico.com/news/2021/04/22/biden-officials-johnson-vaccine-484356
On the other hand, it could be important for the global strategy because it requires only one dose and has a relatively high storage temperature. So I’m glad to see we have a way forward for this versatile product—one that will help avoid rare negative outcomes in the future, I believe.
What am I doing to cope with the pandemic? This:
Vaccine resolutions
Being just days from a full and formal IgG response is making me want to plan so many things. Are vaccination resolutions—like New Years’ resolutions—a thing? If not, I’m making them a thing. Here’s mine, with some preamble.
In January 2020 I started a new job after nearly 2.5 years commuting to Connecticut every day. Those 2.5 years murdered a lot of my social life, with the extreme commute distance burning as many as 6 hours a day just getting to and from work. I was certain that working in Manhattan would make it easier to see people. And for a time—specifically about a month—it did.
The best-laid plans, right? The pandemic just totally ruined that. Once we got to the end of February, I stopped seeing anyone (not that I regret that choice). Then, COVID-19 swept through New York. There is at least one person who, pre-pandemic, I was trying to meet up with but who is now dead.
But I want to try to pick up where I left off, at least to the extent possible. I want to reconnect with people who I haven’t spoken to much at all in years, because finally it feels like I’ll have the time and the means.
Part of that will be trying to get back into things that I used to do—tabletop gaming, especially RPGs, feels like one that is really well-suited to the world post-vaccination. It gets people around a table, doing something fun, that lets us expand our worlds and horizons meaningfully.
Another part will be just having people over. People I haven’t seen in a long time. Even if it’s just to watch the afternoon light turn into sunset over a drink. Again, getting people around tables to have some fun and just be with each other.
That’s my vaccine resolution: get people I like around tables, by whatever means are the most fun. When May 5th rolls around, I’ll get started.
You might have some questions or comments! Send them in. As several folks have figured out, you can also email me if you have a comment that you don’t want to share with the whole group.
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No corrections since last issue.
See you all next time.
Always,
JS
Hi John,
I just discovered your (great) newsletter while searching for information on a vaccination-related matter on which you'd commented previously. I was wondering if you'd be able to provide an update of sorts, as well as comment on a related matter.
In your 11/18/20 issue, in response to a reader whose husband voiced concerns about mRNA technology, you mentioned that a somewhat less far-fetched concern would be that vaccination could generate an autoimmune response. I've seen these issue raised elsewhere here and there.
Do you view this problem as more, less, or about equally likely to occur as you did in November? Do you believe that we have seen signs of such reactions already, if they were going to occur? On a more theoretical level, are there reasons why we *wouldn't* expect such a reaction to occur, e.g., something distinctive about the vaccine-generated spike vs. the virus-generate spike? How worried should we be?
Similarly, an article appeared recently in the MDPI journal Vaccines (not to be confused the with Elsevier journal Vaccine) suggesting that signaling from the spike protein, via either infection or the vaccine, could lead to pulmonary arterial hypertension (see: https://www.mdpi.com/2076-393X/9/1/36/htm), a frightening prospect. How seriously would you take these concerns? (The article has been gaining some traction on antivax-ish corners of the internet. The authors don't seem like cranks, though I know MDPI's peer review practices have been subject to some criticism.)
Virtually everyone I know is at least partially vaccinated, as am I. Reading these things after the fact has honestly made me start to panic a bit.
I'm jealous. They didn't give me a sticker at the Aqueduct. I'm only 4 days from my 2-week anniversary! Which is good, because business travel is a thing again, and Sunday I leave for Massachusetts.