Tag: Vaccines

Asthma, Epilepsy, Antibodies and Long COVID

Posted on by Dr. Nykki

 

a vaccination clinic directional sign

A little break

It was Christmas, and I had a birthday, and then we had a new year’s holiday and I had a couple of days out of the office. I still don’t have any superpowers, but I did get to spend time binge watching The Muppet Show with my kids, so I am counting Parenting as another one of my everyday superpowers that I continue to manifest. 

 

Without intending to, that was a whole two weeks where I didn’t update and – as I mentioned – I received my second vaccine yesterday. I will strive to be a little more consistent in the next week or two. 

 

We’ve seen some news reports lately about severe reactions to coronavirus vaccines. In addition to the reporting system we have always used for severe vaccine reactions, the CDC has rolled out a smartphone-based monitoring system called V-Safe specifically for tracking the health of people who’ve received the coronavirus vaccine. 

 

A recent review of the adverse event reports for a 10 day period in December showed 1.9 million doses delivered (exciting!) and a little under 4,400 reports of “adverse events” (things we’re concerned about).  About 175 of those events were of concern as possibly being severe allergic reactions, and about 21 of those  events appeared to be true anaphylaxis (a life-threatening allergic reaction that overwhelms your body). That works out to about 11 cases of anaphylaxis per million doses – definitely more than the flu shot (1.35 per million), which is why our current practice is to give the vaccine in a clinic that is equipped to identify and treat anaphylaxis. 

 

At regular intervals, V-safe texts me a little survey to find out how I’m feeling, if I have developed any new concerns, or if I have gotten pregnant in the interim (nope). It also sent me a reminder to get my second dose. If you’re getting vaccinated (or have been already) and are not signed up, I’d encourage you to get registered! 

 

I will tell you the same thing I told V-safe: I feel good, but my arm hurt a little earlier today. It started about 18 hours out but at this point in the evening I really am not having any symptoms at all. I will also tell you that I have colleagues who have complained of fever, headache, and generalized yuckiness as far as 2 days out from their second dose, so I’ll continue to watch. 

 

(To give another perspective on risk — although you can’t make a direct comparison — today’s numbers in Indiana show 558,560 individual Hoosiers have tested positive for coronavirus and 8,595 Hoosiers have died of COVID. That is about 15,000 deaths per million cases.)

 

Science continues to move at a rapid rate, and recommendations continue to be updated as we are looking at balancing availability of vaccines with people who need to receive it, as well as looking at the reports of people who have received the vaccine. Since I last posted, the recommendations regarding people who have already had coronavirus have evolved.  CDC’s current recommendation is that if you have had coronavirus within the last 90 days you may choose to wait to receive your vaccine. If you received monoclonal antibodies or convalescent plasma (you should know who you are but if your sick days are hazy your doctor will know) then you definitely should wait 90 days (and discuss with your doctor the best timing for being vaccinated).  

 

We are seeing at least anecdotally some degree of more robust vaccine reactions in people who have already had COVID (in plain English:  If you already had coronavirus, your body is already somewhat primed to recognize and respond to the vaccine, and so it may be more likely that you are going to have a day or two where you feel yucky). It makes sense, if you already have protective antibodies, that you can choose to wait a few months — your immunity is not likely to fade that fast. 

 

However, if you received monoclonal antibodies (that’s an outpatient infusion that ends in MAB), what we are giving you in that infusion is literally a cocktail of antibodies. These are designed to augment your body’s response, targeting and inactivating the virus and limiting its ability to continue to spread through your body.  There’s a similar idea behind convalescent plasma (that’s an inpatient infusion given in some centers to specific patients), except instead of laboratory-grown antibodies, the plasma is extracted from people who have already recovered from COVID-19. 

 

Bodies are not so smart sometimes: your body assumes those antibodies are home-grown – and so, when you receive your vaccine, you may not make quite as many antibodies of your own if you have a whole bunch of artificial ones floating around already.  That’s why we recommend you wait. 

 

I had a little list of questions and thoughts to cover before I took an accidental vacation. I suspect they’re still relevant. 

If I have asthma or epilepsy, should I take any precautions regarding this vaccine?

 

As far as we know, the coronavirus vaccine does not show any increased risks for people who have asthma or epilepsy. However, it’s important to remember that these diseases, like many diseases, have a wide spectrum of severity. We know that some people who have epilepsy show an increased risk of seizures if they have a fever, are under physical or emotional stress, or when they are even mildly ill, and so if you are one of those people you should definitely talk to your doctor about their recommendations. Similarly, if your asthma tends to flare up when you are under stress or not feeling well, you should check in with your doctor.

What if you were tested for antibodies after your COVID-19 illness and were negative? 

Short answer: OK to be vaccinated, although you could certainly consider waiting for 90 days after your recovery.

 

Long answer: 

There’s more to immunity than antibodies. Your immune system also has “memory cells” whose job it is to be ready to recognize a specific antigen (remember, an antigen is anything your immune system recognizes as “not me”) and produce antibodies rapidly.  We don’t completely understand how B and T memory cells are formed and do their jobs, and we don’t have easy tests to measure the efficacy of those cells, but we know that they can last for decades. That’s where the real staying power of vaccines comes in: they activate the memory cells of the body. In fact, there’s some evidence that your memory T cells are activated proportionately to your vaccine response, so those of you who get a hefty reaction to the coronavirus vaccine can take comfort in knowing you’re building immune memory for decades to come. 

 

Should COVID long-haulers have any special considerations?

 

At this point in the pandemic, we recognize what’s called “long haul COVID” as symptoms that develop during or after COVID-19 infection, continue for ≥12 weeks, and cannot be explained by an alternate diagnosis. 

 

Let’s break that down, shall we? It is at this point considered the normal clinical course of COVID-19 to have symptoms for up to 3 months following your diagnosis. Studies suggest at least 1 in 10 (and up to ¾ or more) of symptomatic people will have some lingering symptoms for 6 weeks to 3 months after COVID, and while fatigue is the most common complaint, we are also seeing significant numbers of patients experiencing shortness of breath, chest pain, cough, memory problems, concentration issues, anxiety, depression, and PTSD. My clinical experience — what I’m hearing and seeing in my own patients — tells me this is right on the money.  COVID is no joke. 

 

Long haul COVID patients are experiencing some portion of these symptoms for more than 3 months. As doctors, we are in the business of helping people, but we have very few effective treatments for these symptoms, and so treatment mostly consists of trying to find something that’s measurably wrong (lung damage, heart muscle damage, blood clots, things like that) so we can target therapy. 

 

The good news is that none of this seems to impact your ability to get the coronavirus vaccine. Your immune system may have been complicit in the processes that got you there (we don’t completely understand why people are affected so differently, but immune system responses likely play a part), but it’s unlikely to turn traitor with regard to the vaccine. 

 

Now I think I’m caught up with questions.

 

Pfizer Vaccine Dose #2

Posted on by Dr. Nykki

 

This is our shot

Do I look delighted? Because I am excited! Second dose of Pfizer’s coronavirus vaccine is in.


Now it is a waiting game, as my body replicates, recognizes, and remembers. I’ll pick back up with my #covidvacccine diaries as long as I can carve out time to.

Today, IDoH opened vaccination to all residents over the age of 80. 33,500 Hoosiers over 80 registered for their shot between 9:00 and 11:30 today.

Right now, my arm hurts and my heart is light.

Guillain-Barré Syndrome

Posted on by Dr. Nykki

Covid-19 vaccination card

Ordinary Superpowers

It is the winter solstice today; the shortest day and longest night in this hemisphere. The days will slowly lengthen toward the dawn. Still no new superpowers. I’m going to have to stick with the ordinary superpowers that come with being alive every day. 

 

Injection site report: I have a small bruise on my left arm that I am going to attribute to the vaccine because it looks like it’s a few days old (I did not take a picture of this because it is really just a faintly greenish spot about a centimeter across, and that sort of picture is only of interest to dermatologists and forensic scientists). It doesn’t hurt, even though I’ve poked it repeatedly just to make sure. 

 

Still seeing reports that are consistent with Pfizer’s data (1-2 days of fatigue, injection site pain, muscle and joint aches, and fever in a notable minority of recipients – in the study these were more frequent and more severe in general after the 2nd dose) from other folks who’ve received the vaccine. I’m going back to the gym tomorrow. If my arm falls off, it will make for an exciting report, but I am now 96 hours out or more from my injection. I’ll let you know how my workout goes. 

 

I hadn’t realized how much “can I still smell the coffee brewing?” had become a part of my daily ritual, but it is. I remember when the first anecdotal reports were coming out in March or April that noted almost a third of COVID-19 patients reported loss of taste or smell, and how my colleagues and I made it part of our unofficial criteria long before it was on the ever-expanding list. 

We’ve come a long way. 

 

Also, I could still smell my coffee this morning, and I am glad on many levels. 

If I have had Guillain-Barré syndrome in the past, is it advisable to get a COVID-19 vaccine?  

 

Sort of short answer: Limited available data suggest that it is safe and advisable for the majority of people who have a history of Guillain-Barré syndrome more than a year ago to be vaccinated against COVID-19, but you should consult with a medical professional who knows your particular history in this case. 

 

Longer answer: 

Guillain-Barré Syndrome, or GBS because that’s really long to type, is a name for a group of similar syndromes — but the one that most people generally seem to be referring to can be described to medical professionals as “an acute, monophasic paralyzing illness” and to people who don’t speak doctor as “suddenly, your immune system betrays you horribly.”

 

Your immune system is one of those perfectly ordinary superpowers you have. Its job is to recognize things that are “not you” — foreign antigens — and not only eliminate them, but remember them so that they can’t get so close next time. It’s really good at this, most of the time.

 

Anyone who tells you that we have a full and complete understanding of the immune system is selling snake oil. Our bodies are almost incomprehensibly complex and the more we learn, the more questions we have. We are pretty sure that GBS results from what is called “molecular mimicry” — which is to say that your immune system, while organizing itself to fight against a foreign antigen, suddenly decides that “those myelin cells over there look a lot like this wanted poster I have in my metaphorical hands” and begins systematically destroying the protective sheath that keeps your nerve cells safe and healthy. 

 

People who develop GBS have a range of symptoms from mild (“I seem to have become quite clumsy when I walk”) to severe (“I am on a ventilator because my body has forgotten how to breathe”). It usually gets worse over a period of four to eight weeks and then it starts to get better. At one year after onset, a little under ⅔ of patients have recovered full motor strength, and about 3 patients in 20 will have ongoing severe muscle weakness. The rest are somewhere in between. 

 

That is some terrifying stuff. It’s even more terrifying because we don’t have a complete handle on what, exactly, triggers molecular mimicry. About ⅔ of people with GBS report a recent upper respiratory or gastrointestinal illness, and a short list of pathogens seems to be the primary drivers of this — but rare cases of GBS have been triggered by surgery, trauma, bone-marrow transplant, and immunization.

 

And there’s the rub. Increased risk of GBS was seen with swine flu immunizations in 1976, and with H1N1 and influenza vaccination more recently. Because this is a rare syndrome (1-2 cases per 100,000 people per year), you need really large numbers to discover increased incidences – sometimes combining multiple seasons worth of influenza vaccinations and disease to find any statistical significance. 

 

Our best estimate at this time is that between 1 and 2 extra people develop GBS per million people given the influenza vaccine. Our best estimate at this time is that you are about 7 times more likely to develop GBS in the 90 days following an influenza-like illness (not everyone has proven influenza, because not everyone gets tested) as you would be without the illness. 

 

If you’re still with me here: 

 

Your risk of getting GBS from an influenza-like illness is substantially more than your risk of developing GBS from the influenza vaccine. But we can’t predict whose immune system will suddenly go rogue.

COVID-19 can probably cause GBS; it’s described as infrequent and there remains some scientific controversy, but it is a potential complication of the disease, and we don’t know which particular antigen (part of the virus particle) might make the immune system go rogue. We have not seen an increased incidence of GBS in the Pfizer and Moderna trials thus far. That should be reassuring — but I want you to review the number of times I’ve said “we don’t know” or “our best estimate” about GBS (at least 6). 

Immunization recommendations in general for folks who have had GBS are based on observational data and expert opinion. That means that folks got together and talked about what they’d seen and the science as they best understood it and said “this seems to be the best course based on the information we have.” That means I don’t have a yes or no answer to give you. 

Unless I am your doctor (and if I am we’re not having this conversation on Facebook, call the office!) I cannot give you the kind of personalized in-depth shared decision making conversation that has to happen about your particular case. 

But I do recommend that you call your doctor and have that conversation. 

 

I’m going to hold on to the question about long-haul COVID and vaccines for tomorrow, because there’s a lot to unpack there, and this post is long enough already. 

 

 

 

 

Vaccines and COVID-19 Survivors

Posted on by Dr. Nykki

coronavirus vaccine clinic doors

Long COVID and vaccinations

The personal part of this is short: I’m doing just fine. 

 

I would post a picture of my vaccine site, but it looks like an arm. No redness and no swelling; the vague discomfort of yesterday has resolved completely.  I have taken no more naproxen. 

I’ve felt fine all day – no temperature, no headache despite spending the entire day building a website without my blue-blockers, nothing out of the sort. I almost forgot that I’d promised an update — and another answer to an unanswered question — this morning. 

I’ve been following a lot of my physician friends and remembering how many people I know. A lot of them have been vaccinated recently. Some of them have had aches and pains or headaches, but everything seems to have settled within 24 hours. 

The vaccine’s mRNA in its liposomal envelope has by now been delivered to the protein factories within my own cells, translated into instructions, and discarded. It’s not particularly stable, which has been a limiting factor in mRNA vaccines until now. 

I have visions of my immune system printing off tiny “Wanted” posters with a picture of the spike protein on it and passing them around. I hope my B cells are taking a good solid look. I hope my T cells are remembering. I hope that at some point we’ll have some idea of what level of antibody titers are protective. 

I hope we keep listening to science. 

 

Things I don’t know about this vaccine but I trust science to answer eventually:

If I already had COVID-19, will the vaccine still help me?

 

Short answer: We don’t know for sure, but probably. 

 

Long answer: the rest of this post. 

 

I happen to know that I almost certainly have not had COVID-19. Not only because I’ve been asymptomatic (see previous post regarding asymptomatic/presymptomatic carriers), but because I’ve been tested – with PCR testing – regularly enough that it’s statistically unlikely I would have accomplished a sufficiently long string of false negatives to have had asymptomatic COVID-19 and missed it. 

Translation: Someone shoves a wire Q-tip up my nose on a regular basis, and while one negative test may still be wrong, a whole bunch of negative tests are probably right. 

 

However: 

A lot of people I know HAVE had COVID-19. This is about those folks. After all, their immune systems have seen the real actual spike protein and beaten it down, so we know their T-cells and B-cells should be super aware, right? Do they need to get the shot?

 

Answer: I don’t know for sure — but they will probably need it at some point in time. We don’t know what that ideal point is. 

We do know that immunity wanes over time. Those little Wanted posters get ragged around the edges and the old guard – the ones who remember the all-out war your body once waged – turn over for newer cells. After a while the stories get old. After a while, your body forgets. 

How long it takes to forget is something we don’t fully understand — and something that can vary widely from person to person. For example, if you have whooping cough, you’ll be pretty much immune to another bout for somewhere between 4 and 20 years (for comparison, the whooping cough vaccine lasts between 4 and 12 years). That’s a pretty huge spread, and we’ve known about Bordetella pertussis for about 115 years (we’ve had a pertussis vaccine in some form for close to 90 of those years).

We’ve known about coronavirus infections for about a year now. We’ve been able to test for coronavirus antibodies for about eight months — but we’ve only had an approved test for neutralizing antibodies (the ones we really care about) since November. We just don’t know at this point how long any immunity lasts for sure — although the tests we do have suggest that people who have COVID-19 produce antibodies for at least 2-3 months — and we really don’t know how long vaccine-mediated immunity lasts.   

But an educated guess says that even if you’ve had COVID, getting vaccinated should help stretch your immunity out a little longer.

 

Update on 1-16-21: The CDC currently states that people who have had COVID may consider waiting for up to 90 days before receiving COVID vaccinations; we have anecdotally seen that people who get their vaccines shortly after recovery have more robust reactions. 

 

Vaccine Protection Questions

Posted on by Dr. Nykki

a portion of the EUA consent for Pfizer vaccine

24 hour vaccine report

I was contacted yesterday early afternoon by our incident command asking if I had really meant that I was willing to participate in rollout testing for our COVID vaccine program, because if so they’d love to have me between 4:30 and 5 to get my shot. 

 

I am prone to enthusiastic responses to vaccines, and am somewhat notorious for developing a 6 to 8 in welt on my upper arm after getting my flu shot. I did not have that response this year to the flu shot, and it was such an anomaly that half the office had come by to look, so I did give the idea some careful consideration. 

 

I had actually planned on doing my initial vaccine next week on the 23rd of December because nothing says Christmas presents like monitoring yourself closely for vaccine reactions.  I am also on-call this week, and part of the risk of getting vaccine is having a reaction, but after review of the literature available to me I felt like probably the 2nd dose is more likely to cause an issue that would actually get in the way of me doing my job (we’ll see in three weeks),  and I am quite frankly a sucker for being helpful if it means making history happen.

 

So I got my 1st coronavirus vaccine around 5:00 yesterday afternoon.

 

For complete transparency, I went to the gym on Wednesday the 16th of December and did upper body reps until failure in multiple supersets. When I went in to get my vaccine last night, I was already having some low-grade muscle aches throughout my upper body.

 

By bedtime I had essentially no response. I had no increase in pain in my upper arm, no erythema, nope welt, nothing at all. There was in fact so much nothing that I made my husband take a picture of it so that I could really see, and – in his words – “one of the two spots in this picture is a freckle, and one of them is where the shot went in, I can’t tell which one is which.”

 

I woke up this morning with two sore arms. My right is the usual discomfort I expected from the gym on Wednesday (foam roll, people, it’s real) but my left arm is definitely a little more painful than the right. My deltoid has a dull ache in it every time I lift my arm. It’s not enough to stop me but it’s a reminder. I took some naproxen, because that is my analgesic of choice. 

 

That ache has continued through most of the day so far; this morning it was a gentle reminder every time I use that arm, but this afternoon (without any more naproxen), my arms feel pretty much the same. I still have no significant redness, no swelling, and no actual tenderness at the site.   Currently, rating this somewhere between the flu vaccine and the Tdap (which hurts).

Questions I don’t have answers for about this vaccine: 

Does this protect me from giving COVID to others?

I don’t know for sure. When scientists design an experiment, they determine what they are testing and how they are testing it in advance. Sometimes it is possible to use the data from an experiment to draw other conclusions, but we always have to be careful when using an experiment to answer questions it wasn’t designed to ask. 

We know from the remarkable data gathered by the  Fairbanks School of Public Health and the Indiana Department of Health early in the pandemic that something like 40% of people who were positive for coronavirus DNA were asymptomatic or pre-symptomatic.   These patients can only be detected through surveillance testing ( either testing everyone in a certain set of people or testing known contacts of ill persons) or by testing them when they develop symptoms later, and are known to be transmitters of the virus.

The vaccine trials that were done and are still ongoing were not designed to test for asymptomatic coronavirus infections.  Testing for COVID-19 through the trial protocols was only done on symptomatic individuals – people who were sick in some way. Because Pfizer didn’t test everyone on a regular basis regardless of symptoms, we don’t actually know what the prevalence of asymptomatic infections was in this study.

That means I’m still wearing my mask to protect you — and perhaps now it’s even more important for me to do so. 

How long does the vaccine protect me for?

I don’t know. We just don’t have the long term data on efficacy yet. We can hope that immunity will be measured in years (although a seasonal vaccine, like the flu shot, is still very much a possibility).  We can also hope that enough people get the vaccine and have enough immunity to mitigate the seriousness of infections, reducing the health care system overload and giving us time to develop effective treatments for this disease.