October 27, 2021
“I don’t think anyone should die from Covid now. This is an avoidable death. People with intact immune systems have vaccines available to them, highly effective vaccines.
There are two pockets of vulnerability – young children who we will eventually be able to vaccinate, and people who are immune incompetent that can’t mount an effective response to the vaccines because they are organ transplant patients or receiving chemotherapy. We have the tools to protect them. We could be using the antibody drugs on a prophylactic basis, giving them monthly infusions to protect them from the virus … Regeneron is making them available on a compassionate use basis for that purpose.”
Dr. Scott Gottlieb, former commissioner of the FDA, 2017-2019 from Face The Nation October 24, 2021
We are seeing the beginning of the end of this pandemic, just in time for the holidays. Case numbers are coming down around the country, as additional individuals decide (or are mandated) to get vaccinated, vulnerable vaccinated individuals get booster shots, and millions of people recover from recent infections from the Delta variant, with robust immunity to the virus. The vaccinated and the unvaccinated survivors of the virus who are now immune, remain. And the departed, well they will remain departed. By the end of the year, about 800,000 people in the United States will have died from Covid-19. The last 20,000 deaths, which have occurred since the summer, were almost entirely unnecessary, preventable by vaccination.
General Colin Powell, who died last week from complications of Covid-19, is likely an example of a preventable death. General Powell completed vaccination with the Pfizer vaccine in February. He had an underlying condition, multiple myeloma, a form of bone cancer, which would have affected the strength of his antibody response to the virus. If recommendations released by the FDA in August 2021 to vaccinate immunocompromised individuals who had received their last vaccination 6 months ago had been followed, he should have received a booster vaccine in early September. He was scheduled to get the vaccine this week. A day late and a dollar short.
In our practice, we have seen about 2 dozen breakthrough infections – patients who were previously vaccinated, became symptomatic with Covid symptoms, and tested positive. One of those patients was hospitalized after a fall caused by dehydration from the virus. The others recovered without hospitalization. All the breakthrough infections have occurred since the Delta variant became dominant, in those vaccinated early on with the mRNA vaccines, who had not received a booster shot, or those who received the Johnson and Johnson vaccine more than two months prior to their illness.
The current situation is analogous to a football game. The home team is our individual antibody level to the virus. The viral load in the community is the visiting team. The one with the high score wins. For us to win we need to keep our antibody levels as high as possible. And the game plan to achieve this is straight forward: get vaccinated and get the booster shot, if appropriate, on time. (Colin Powell’s doctors missed an opportunity to score by letting the clock run out before he was re-vaccinated). The visiting team is tricky. It is constantly running quarterback sneaks and double reverses to fool us. Descending on a wedding or funeral, infecting unvaccinated and under-vaccinated folks by the dozens, and sending them back out on the playing field to infect others.
The home team has a better game plan, because it is foolproof if the whole team follows it. But we have some weak players, who are not pulling their weight. They are not getting timely vaccinations, and letting the quarterback get sacked. The virus has a flawed game plan, with a random and haphazard strategy. But every one of its players are equally competent and can overcome a weak unvaccinated or under-vaccinated home team player. We are about to win the game, but only after losing 800,000 players. Or more.
After about 2 months of public hand wringing, the FDA/CDC seems to have gotten their recommendations for booster shots and childhood vaccinations right, making them available to the vast majority of people in the country. The message has been sent to pharmacies and others administering the vaccine to err on the side of vaccination – don’t deny people booster shots.
So, if you have received the Pfizer or Moderna vaccine, and are six months from your second shot, get a booster of the same Vaccine. If you received the Johnson and Johnson vaccine more than two months, ago, get a booster with the Moderna or Pfizer vaccine. If you are immunocompromised from current chemotherapy, cancer, diabetes, etc, make sure you get a timely booster. Children aged 5-12 will be eligible for vaccinations within two weeks. Decisions about vaccinating kids should be made in consultation with their pediatrician. Childhood dosed vaccines will be made available to pediatricians’ offices, likely by early November.
We are about to win this game, though we will go to the locker room with many bruises and fallen teammates. There could be a new game next week, next month or next year with a stronger opposing team. We will have to change our game plan. That game plan may involve a new mRNA vaccine based on the “Delta platform,” prophylactic monoclonal antibody treatments given on a regular basis to the most vulnerable immunocompromised patients, and oral antiviral therapeutics to treat infections in the outpatient setting. We will win the new game too, hopefully with players who have learned some important lessons.
Stephen Katz, MD, Adult Internal Medicine
Severna Park Medical Associates
Concierge Medicine for Annapolis
31 Robinson Road Severna Park, MD 21146