Booster

 Will the current crop of anti-COVID 19 vaccines hold up and keep us all safe from infection?

With the existing trend of COVID-19 infections, everybody is asking whether there is a need for additional vaccine doses. The new COVID-19 variants have put into question the vaccine’s effectiveness against mutating strains of the virus.

Booster doses are given to sustain protection against prevailing diseases.  Just like the vaccine for hepatitis B, for instance, the antibodies they provide may wear off with time. For the flu vaccine, boosters are provided yearly. This may also be the case for SARS-CoV2.

There is currently no clear-cut study indicating the need for booster doses of COVID-19, according to the Centers for Disease Control (CDC). Although some drug companies have made previous suggestions of lowered immunity after 6 months of immunization, this has not yet been substantiated with clear-cut recommendations for added vaccination. We need more data for this, as this would entail added costs. Is it cost-effective to add another dose for everyone?  We do not have the answers yet.

The existing vaccines have proven effective in stimulating the body’s immune response against COVID-19.  According to research studies, the memory B cells are able to produce antibodies once we are exposed to the virus or to its fragments.  This happens at least 12 weeks after infection or after immunization.

Research also reveals that COVID-19 vaccines can protect against mutant COVID-19 strains, so there is no need to be too concerned about mutant variants being resistant to the vaccine.  The Johnson & Johnson vaccine, for instance, had 73% and 82% efficacy 14 days and 28 days post-immunization against the beta variant. The Pfizer vaccine was also found to be 88% effective against the delta variant. However, boosters may be needed if an outbreak is declared. 

The best way to measure whether the vaccine induces the immune system is by measuring the antibody titers of individuals.  Some vaccines seem to induce antibodies better than others, but overall, the approved vaccines have proven to be effective in increasing antibody titers.  If and when researchers get to know how to measure vaccine-induced immunity, the next indication that boosters may be needed are breakthrough infections in older adults who have already been vaccinated.

Older individuals over 80 years of age make lower levels of antibodies after vaccination, so their immunity may disappear sooner than that of younger individuals. They are also the most vulnerable to new viral variants. Boosters may thus be necessary for them, together with those with compromised immune systems such as chronic steroid users and cancer patients. The people may not be able to produce antibodies in adequate amounts.

COVID-19 vaccines have not yet been thoroughly tested in people receiving palliative or end-of-life care, so there is some hesitancy in giving these patients the vaccine. This is because Phase I Clinical trials for new vaccines start with young healthy volunteers who have no comorbid conditions. However, results from the COVID-19 vaccine programs in Scotland and England on Pfizer-BIONTECH  and AstraZeneca suggest that both vaccines are very effective at preventing serious illness in people aged 65 years and older. People in this age group who had a COVID-19 vaccine were much less likely to be hospitalized due to COVID-19.  Thus, if they can be vaccinated and they can tolerate the possible adverse effects, they could receive immunization. It would take more studies to make a more conclusive statement, but it looks like the benefits of immunization outweigh the inherent risks for those with chronic illness.

Twenty Years After 9/11

Each of us is unique. Let us think highly of one another.

It was an ordinary day for most of us on September 11, 2001. I was on duty at the Philippine General Hospital, where I had my residency training in Family and Community Medicine. At around 8 in the evening, I saw a video clip on TV showing a plane crashing into one of the towers of the World Trade Center in New York. I thought it was a movie trailer. It was not. It was reality.

Today, I am reminded of the impact this terrorist attack had not only on those who were at the scene, but for the whole human race. Some responded with fear, living with possibility of dying while inside a tall building. Others let discrimination build inside them, eyeing bearded colleagues as potential terrorists who should not be given access to any public domain. Past exposures carry a lot of weight on how we behave in the future. And the specter of death grazes our consciousness whenever we lose friends or loved ones in unexpected circumstances.

Why does disaster carry this much influence on our thoughts? It is because we are all, in one way or another, afraid of uncertainty, especially death.

When we are young, we live like we are immortal. We shrug off physical pain easily. We recover from illness faster. But when we hit old age, the reality of leaving this world sinks in. Even then, I have seen people who could never accept that they will die soon. They bargain. They beg. They petition the heavens. Losing all their ideas, thoughts, and emotions is an unbearable undertaking.

Who among those in that tower ever thought that it would be their last day on earth? Sadly, no one was able to tell. Can we predict when we will leave this planet? Unless one is suicidal, nobody can. The terrorists on the hijacked plane were probably the only ones who were ready. But then again, we could argue that they had distorted views on life and eternity.

Do we now have respect for the human race? Do we still discriminate? Are our perceptions still clouded by our differences in culture, speech, and traditions? These biases are the ones that carried hatred and brought about the ensuing carnage. In one way or the other, have we learned to treat everyone with respect and dignity?

The attitude and air or superiority, and the feeling of being bullied and subdued, elicits the kind of hatred that costs human lives. It may start within families. It can escalate between neighbors. It then brews within communities. Finally, it explodes between races.

Let us put a stop to these harmful human tendencies. It spreads easily, and when it attains its boiling point, the only way for it to cool down is to annihilate everyone in its path. Everybody may eventually be harmed once the bullied child gets into a position of power and influence. You may win the war now, but the enemy remembers and takes its time to exact revenge. It is going to be a never-ending cycle of hatred. Unless someone takes away the oxygen and says “let’s stop this inferno.”

We only live once. We will all leave this world. But when we do, let’s leave a legacy that will foster love and respect for each other’s differences. It will not just sustain us. It will keep us rational and sane. And hopefully, those that remain get to pass it on and improve along the journey.

Whatever good we can do today will extend to future generations. The only way to end the 911 attacks is to nourish and nurture the art of respect.

Perseverance

It’s Olympic Season! Although this is an unusual Quadrennial (delayed by one year) meet due to the pandemic, it does not take away from the spirit of competition. The same desire to win persists. And the inspiring stories remain the same.

Art by: M.H.

Everybody knows the golden exploits of weightlifter Hidilyn Diaz, the first Filipino gold medalist in Olympic history. But behind that triumph, only a few remember her as a young Olympian who failed in previous attempts for a medal. In 2008, she was at the bottom of the standings. In 2012, she did not complete her clean and jerk event. Her breakthrough was in 2016, and with it, came higher expectations. Those expectations became a reality in the recent Tokyo Olympics. Although the pandemic caused her to be stranded in Malaysia, this did not prevent her from pushing through and lifting a new Olympic record. 

Carlo Paalam, our Olympic silver medalist in boxing, also has a great story.  His mother left their family when he was six years old. A former scrap collector, he rose from obscurity and made us all proud by beating a former Olympic champion. He also overcame great odds by beating a Japanese fighter in his own turf. Although Tokyo is his first Olympic games, he showed that he was ready. After winning the silver medal, he recalled all those scraps he collected, and said that it symbolized all those metals he scavenged in his life. His life will now change as he is set to win millions in prize money for his performance.

What do these narratives tell us? Do they mirror our own struggles? Do we also feel victorious when someone close to us experiences a win? Do we also celebrate the success of others?

We associate ourselves with winners, and embrace their struggles. Their triumph becomes ours too. As caregivers in the health sector, no amount of remuneration can replace the joy of seeing a dying patient recover from illness. It is not the just sick who persevere, but also those in-charge of patient management. If money were the sole motivation, not a few doctors and nurses would tell you that they might have quit a long time ago.

What if there is no improvement in sight? Hospice patients face this dilemma. How does one persevere when there is no end to suffering?

The answer? Celebrate little victories. The pain-free moments. Or even just moments when pain is less. The ability to still maintain one’s quality of life despite the terminal illness. The presence of friends and loved ones.

There is also a significant contribution of teamwork in every triumph. Although weightlifting and boxing are individual sports, there are people behind Hidilyn and Carlo who made them who they are today. It was not just their trainers and coaches. Their families also provided great support. Even the whole community, the Filipino people, who cheered them on, played a role. The same is also true for taking care of the sick and dying. They must not be left alone. There must be a team of doctors, nurses, and caregivers who look after them. And their loved ones must not leave them behind.

We always have a choice whether to push through or just let life pass us by. It’s the choices we make that will ultimately determine our happiness. Perseverance pays off, both in sports, and in life.

Not Just A Number

“When we are no longer able to change a situation, we are challenged to change ourselves.”

—Viktor Frankl, Man’s Search for Meaning

I just pored through Viktor Frankl’s book, Man’s Search For Meaning for the nth time. It is an eye-opening and brain-enriching piece of work. Essentially, it tells us that finding meaning in life is one of the most important things to find out to enjoy one’s existence. This enables us to push through adversity.

Why do we go through tough exams as medical students?

Because we know that after all the hardships, we can be doctors who can make a difference in the lives of others.  Through the long hours of study and sacrifice, we see an end that is meaningful and productive. Future earnings may be a good motivation, but once a certain amount is reached, having more may no longer inspire.

Passing through this current medical crisis and the challenges and heartaches it carries is taxing to the psyche. It also exposes the different ways people react to trials. Some become numb and resigned to fate. Some become ultra-aggressive and take advantage of others. But a few find the courage to live through the pandemic by being of service to others.

Frankl tells of how the prisoners in the Nazi camps of Auschwitz were dehumanized and reduced to mere numbers for identification and segregation. The only things that were left were his belt and his eyeglasses, as all including his family was lost. What kept him going was his ability to see the world as it is and find meaning to it. Being human is always directed towards something or someone. Self-actualization is a transcendence of the human self. The fulfillment of a human need is only attained through others.

As a physician, this is what we must be able to emphasize to our patients. We tend to paint a picture of life’s beauty for those who have lost hope in living, imposing our will in the process. Probably, a better approach would be to give our patients a “new pair of eyes” to see meaning without imposing. It is indeed more therapeutic when you discover meaning by yourself. This makes you own the goal, and with the support of others, this makes the goal a shared ideal which can foster bonding and camaraderie. Maybe it’s time to shift the patient’s focus to something other than their own predicament.

Suffering ceases to be suffering once it finds meaning. We might mourn indefinitely for our loved ones who suffer from debilitating diseases and die, impacting our daily existence. When this happens, we must look for hidden tenets of wisdom to make sense of the situation. What if you were in the situation of your loved one? What would you have wanted them to do under the circumstances? The truth is, we may have to flip the page to see the other side of the passage.

We are not just numbers or pieces of DNA. Science tends to do this — reduce us to mere pieces of data to find objectivity. However, life is never fully objective and impartial, for we are human. We have feelings. It is what makes us who we are. It is the essence of our existence.

IS SINOVAC EFFECTIVE?

With the concern about the efficacy of vaccines being questioned, the timing of the medical worker outbreak in Indonesia raises valid concerns. Hundreds of health workers were said to have been infected after being given complete doses of Sinovac, a biopharmaceutical company. Some patients were hospitalized with decreasing oxygen saturation levels, which indicate a serious condition.

There are a few issues that need to be addressed in this latest outbreak. Let us try to look at them and see if we can find the answers based on the information available.

First, the World Health Organization (WHO) approved emergency use of Sinovac's vaccine as it showed at least 51% of recipients benefitted from having less severe COVID-19 symptoms, leading to less hospital stays. None of the tested patients were hospitalized for COVID-19. However, this puts into question the strain of COVID-19 that was tested in this study.

The Delta Variant, first detected in India in October 2020, poses the greatest concern, as it is said to be driving the current outbreak. This variant shows increased transmissibility and virulence. It is feared that the Sinovac vaccine is ineffective against this strain. However, there is a need to do further studies on this. Nothing is conclusive.

The second issue involves the decreased vigilance among the populace. Some of those given the full dose of the vaccine mistakenly believe that they are now immune to the disease, so they become less careful. This includes the health workers who were among the first to be vaccinated. During public holidays, the increased movement of people becomes a risk for transmission.

What is important, however, is that we follow safety protocols. Being fully vaccinated is not a license for us to lower our guard. We must still wear masks when we go outside until we are able to control the spread of this menace.

Why are there different COVID-19 strains?

Just like most living organisms, adaptive mechanisms enable us to survive in adverse conditions. For viruses, mutation is the mechanism to improve “survival” even though they cannot replicate outside a living cell – or outside the human body. Viruses are known to mutate easily. This enables them to “escape” destruction and identification by the immune system. The changes in their structure leads to the development of different COVID-19 strains. When a virus is spreading, the likelihood of the virus mutating increases. The more opportunities a virus has to spread, the more it replicates.

Some strains can still be neutralized by the currently available vaccines.  This has been proven in studies that came out this year.

According to the World Health Organization, the COVID-19 vaccines that are currently available are expected to provide at least some protection against new virus variants. This is because these vaccines elicit a broad immune response involving a range of antibodies and cells – meaning the mutants will still be neutralized by the drugs.  Alterations in the structure of the virus should not make vaccines completely ineffective. In the event that any of these vaccines prove to be less effective against one or more variants, it will be possible to change the composition of the vaccines to protect against these variants.

Should we avoid Sinovac because of this?

The simple answer is no. Science has proven the effectivity of the vaccine, despite the recent news articles stating otherwise. It is understandable to have certain apprehensions when there are doubts as to the effectiveness of prevention due to outbreaks. However, unless our health authorities say that it is unsafe or ineffective, there is no reason to doubt science. After all, it is science that will enable us to pull through this crisis.

Life After COVID-19

The coronavirus pandemic has changed our way of life. And if you were infected, there may be certain signs and symptoms to watch out for.  According to health experts, some COVID-19 patients develop long-term organ damage and have a prolonged stay in the hospital before making a complete recovery.  Most patients also report changes in breathing patterns and blood clotting mechanisms after recovering from the infection.

After COVID-19, there is a residual damage to lung alveoli and to endothelial cells that line the blood vessels, leading to persistent respiratory symptoms and excessive blood clotting across the body. Some of them succumb to eventual pneumonia and cerebrovascular disease. This so-called post-COVID syndrome happens after the initial infection of COVID-19 is over and the patient is deemed to have recovered.  Patients may have a recurrence of symptoms such as lethargy, body aches, and itchy throats.  This may have an effect on their mental state leading to anxiety and depression. It is therefore of essence to monitor patients after infection or discharge from the hospital.

Co-morbidities or other illnesses, exposures, or demographic characteristics such as smoking, diabetes, hypertension, and renal disorders also contribute to immune compromise and added risk for complications.  Gender differences have not been observed, but some studies indicate more distressing signs and symptoms among males compared to females.

It is important for COVID survivors to monitor oxygen saturation, which must not dip below 95% using a pulse oximeter.  Respiratory symptoms must also be monitored, taking note of the presence of cough or difficulty of breathing.

Temperature must also be monitored, which must not exceed 37.8 degrees centigrade. There must also be no signs of easy fatigability, sleepiness, and change in sensorium.  Patients with Diabetes Mellitus should regularly monitor their blood sugar levels.

There is a need to have a regular check-up with a trusted doctor after one week of being deemed recovered, and every 3 months thereafter.  Blood investigations may be warranted in order to screen for signs of inflammation.  Some would recommend chest imaging studies after 3 months to ensure pulmonary recovery.

The most dreaded complication would be the emergence of a cytokine storm, where immune cells attack vital organs such as the lungs and the heart. Another complication is a blood clot that can manifest as a heart attack or stroke. Therefore, blood pressure readings that fluctuate or go down must be reported at once.

Vaccination must be made available to post-COVID patients to help minimize infection and viral transmission. So far, all vaccines available in the market have shown an increase in antibodies after administration of the vaccines. There is also an increasing trend towards immediate administration of the vaccine after COVID symptoms have been resolved. This means that you no longer need to wait for a long time before you can avail of the vaccine’s preventive benefits.

However, the most important message after being infected is that there is hope. We have made great strides in the prevention and treatment of COVID-19.  We must trust that in these situations, science will prevail, and the human race will move on and learn from this crisis.