Breastfeeding, Pregnancy, and coronavirus vaccines

Posted on by Dr. Nykki

 

Babies are some of my favorite patients

My arm only hurts if I push right where I got my jab (what a delightful term). I made it through a topsy-turvy clinic schedule without excessive fatigue, and I currently have nothing to complain about to the nice folks at V-safe who sent me my daily reminder text to find out how I was doing. 

 

I also do not have any new super powers, unless you count filling the dishwasher without being asked to (I am a terrible housemate).

Can I (should I) get the coronavirus vaccine while pregnant or breastfeeding?

 

Short answer: It depends. 

 

Long answer: 

Let’s talk a little bit about how mRNA vaccines work so that we’re all on the same page with regard the science of vaccines, because I think that helps answer the question. There are, after all, some vaccines that you are NOT currently recommended to get while pregnant (MMR, Varicella, Live influenza, Zostavax; HPV, Meningococcal B) so the question with a new vaccine is certainly relevant.

 

Vaccines work by introducing your body to an antigen (A recognizable part of the thing we are protecting against) in some sort of low threat way. Bodies are excellent at recognizing things that do not belong — and not only do they seek and destroy, but they create specific antigen binding molecules called antibodies, as well as engaging your T and B the memory cells to remember, locate, and inactivate that particular antigen should ever be encountered again. There are no three strikes rules in your immune system.

 

One of the first widespread vaccines in the Western world was the smallpox vaccine. The process of smallpox vaccination (ask anyone who was a vaccinated child prior to 1972 about their scar) involves scratching a hole in the skin and introducing a close cousin to smallpox called cowpox into the hole. Cowpox is much less deadly than smallpox, and vaccinating with cowpox dramatically reduced the attack rate of smallpox, which is a disease that now has the dubious distinction of existing only in the laboratory. 

 

We still use live virus in some vaccines today. The MMR, Varicella, live inactivated influenza, and Zostavax (old shingles) vaccines use a live inactivated virus – real viruses that have been in some way altered to make them slow and sluggish; easy prey for a nimble immune system. However, as any pregnant person can tell you, pregnancy makes everything in the body go haywire – including the immune system. So we don’t give live virus vaccines to pregnant people (or people with heavily suppressed immune systems) because of the risk that the virus could pose to parent or baby if it proved to be too quick on its feet. 

 

The majority of vaccines today don’t use whole live virus, inactivated or not, because we’ve learned a lot of more predictable ways to present antigens to our cells. I’ll save the lecture on vaccine subtypes, but mRNA vaccines are a whole new way of presenting antigens from a public health standpoint. 

 

And that’s a big part of the anxiety around these vaccines, right? This is all new technology, after all. 

Except that it isn’t. In the oncology research labs, where some really amazing scientists keep trying to find better ways to treat cancer, mRNA vaccine technology has been under development for more than a decade. It’s not, actually, all that new. It’s just never been used for -this- type of vaccine before.

 

Your cells contain vast lengths of DNA – the instructions for making the proteins that make you –  folded up into those infamous double helices and stashed in the nucleus in tightly knotted chromosomes. In order to make a protein, a lot of complicated biology happens to make a copy of the relevant section of DNA, using a strip of bases known as mRNA. That’s short for messenger RNA, which is exactly what it does: mRNA takes the instructions from the DNA and carries them into the ribosomes, where it’s used as the blueprint for assembling amino acids into a protein. 

 

Enter the mRNA vaccine. When you are injected with an mRNA coronavirus vaccine, your body is handed a whole bunch of little instruction manuals for making an easily recognizable part of the coronavirus spike protein. Because RNA looks like RNA no matter where it came from, your cells pick it up and hand it over to the ribosomes. The ribosomes do their thing, and voila! Your cells have made a viral antigen. It’s recognizable by your body as Definitely Not Me, and so your immune system gets to work recognizing, remembering, and neutralizing. There’s no actual coronavirus involved in the administration, and nobody has to get scratched with a stick and rubbed with cowpox. 

 

Still with me? That was a lot of immunology. 

 

Back to our pregnant-and-nursing people who are still waiting for me to explain what all of this has to do with them, then, and I’ll explain. 

 

There are two types of vaccines that we don’t recommend giving during pregnancy: live inactivated ones (because your immune system is being deliberately suppressed by your body in order to avoid letting it notice that you’re growing a person who is about half Definitely Not You, and so we don’t trust it to catch the live virus in a safe and efficient manner), and vaccines for which we don’t have enough safety data to make a call yet, but where delaying vaccination for nine to ten months is unlikely to pose a significant risk to the pregnant person. 

 

And that’s where it depends. 

 

You see, yellow fever is a highly contagious infectious disease in some parts of the world — and the only vaccine we have is a live inactivated one. But because the risk of dying from yellow fever is so high, the yellow fever vaccine is still recommended in pregnancy if you can’t avoid going to an area where you are at high risk of catching it. 

 

We don’t have enough data on either of the coronavirus vaccines in pregnancy (see yesterday’s post on the power of numbers) to make a clear statement about safety. The science says that there is nothing in the way the coronavirus vaccine works that would pose a threat to a developing infant (it’s just a set of instructions, after all) — but I don’t have an absolute answer to give you here. 

 

If you are pregnant and you get COVID-19, you are more likely than a nonpregnant person who’s otherwise just like you to have severe COVID-19 disease (including ICU admission and death). You are also at increased risk of preterm labor and delivery, and of having a cesarean section at that delivery. Those are notable concerns!

 

Being vaccinated in late pregnancy may allow your body to pass antibodies across the placenta to protect your baby, as well. That’s why we give pregnant people a Tdap vaccine at 28 weeks – to help protect babies from whooping cough through what we call passive immunity. The body is designed to pass antibodies through the placenta to a growing baby, in order to help protect that baby against things that its immune system is likely to encounter. Developing passive immunity through vaccinating pregnant people has not been tested with coronavirus vaccines, but it’s likely that it will happen to some degree. 

 

If you are pregnant and eligible for the vaccine, you should talk to your doctor about being vaccinated so that you can make the best decision based on the data available. If your risk of exposure to COVID-19 is high, then you and your doctor may decide that getting vaccinated is the safest course. If your risk of exposure is low, then maybe you will make a different decision. 

 

What if I want to get pregnant soon?

 

There’s no reason that we know of to avoid being vaccinated if you’re planning to get pregnant. We aren’t aware of any effects on fertility related to the vaccine — and the spike protein is pretty unique. Remember, we are teaching your body to recognize a single part of the coronavirus itself – so if there were concerns about fertility related to coronavirus immunity, we would be quite likely to see them in people who had recovered from COVID-19. 

 

What about breastfeeding babies?

 

mRNA is very fragile. It’s designed to run a set of instructions from one part of a cell to another and then be recycled. Remember all those amazing ultra-cold freezers that the Pfizer vaccine required? That’s because mRNA breaks down very quickly at room temperatures. The vaccine itself is unlikely to make it to your baby through breast milk — but if some of it did survive that long, then being doused in hydrochloric acid in the baby’s stomach will finish it off. 

 

What we know is that antibodies are expressed in breast milk and are another source of protection from infection for a growing baby. Being vaccinated while breastfeeding is likely to provide some passive immunity for your baby, and is unlikely to cause any harm to them. However, some people are very sensitive to illness, and because they may feel poorly for a day or so (I hope everyone’s vaccine experience is as flawless as mine!), that may affect their ability to breastfeed (it’s still safe, but nursing a baby when you feel like dirt is No Fun) or to maintain milk supply (stay hydrated!!!) through those days. It may take extra effort to make sure breastfeeding the baby continues without interruption.

 

There are trials being started now (in animals) looking at reproductive safety specifically, so if more data emerges, I will try to update!

 

 

 

Vaccination and asymptomatic infection spreaders

Posted on by Dr. Nykki

 

I was vaccine hesitant, too

Today’s update: If I push on the spot where I got my shot it’s a little sore. Otherwise, I’ve been in excellent health.  I continue to hear reports of low-grade fevers, fatigue, and headaches from others, so do be aware your experience may not be quite as uneventful as mine. It all depends on how enthusiastically your immune system gets involved, and how sensitive you are to that activation.

 

I have a confession to make: As delighted as I am to have received my shots (and my delight and enthusiasm are not feigned), I spent the greater part of 2020 skeptical about the creation of, development timeframe, and efficacy of any theoretical coronavirus vaccine. I spent several months in the late summer and early autumn anxiously fretting about political pressure and the timeline of a vaccine release. I made up my mind that I was going to wait – 3 to 6 months, approximately – after the large-scale release of any purported vaccine before I got my shot. 

 

I worried about timing. I worried about who I could trust. I worried about what would happen if this shot didn’t actually work well enough to stop the pandemic (at one point, we were hoping that the vaccine would be 50% effective). 

 

So what changed? 

 

In September, a number of major vaccine manufacturers released their trial protocols. Part of being a responsible scientist is designing your experiments in advance, and releasing the trial protocols meant basically that the manufacturers told us what they were looking for, how they were measuring it, and what the criteria were for announcing success before the formal end of the trial. 

 

Understanding what we were testing gave me more confidence than any ongoing news scrutiny — and knowing the numbers that would indicate a tentative success (something that many trials, not just these, have baked into their protocols) – publicly – in advance – restored additional confidence. 

 

And so when the data was released, and the early results were tallied, my questions were no longer about fundamental issues of trust (although one should always continue to ask questions). They were about points of science – in a field where my training gave me enough knowledge to know what to ask. And that’s how I found myself getting my shot in December – and excited to do so – but still wearing my mask, even now. 

 

One question tonight.

It was going to be two – but I write really long posts.  So tomorrow: mRNA and vaccination while pregnant or breastfeeding.

Why are we talking about vaccinated people spreading coronavirus? Wasn’t that the point?

 

Short answer: About one in 20 people who are vaccinated are still going to get symptomatic COVID-19 (although it’s likely to be milder), and we don’t know how well the vaccine protects against infection that doesn’t cause symptoms. 

 

Long answer: Ready for some math? 

 

Remember when I said that the vaccine manufacturers told us what they were looking for? That’s a really important point in understanding what’s going on here. You see, when the vaccine trials were designed, they were designed to test for efficacy against symptomatic infection. Pfizer and Moderna both tested any trial participants who showed symptoms as part of their protocols, but they did not perform routine surveillance testing (testing everyone in the study, symptoms or not, at regular intervals) as part of their protocols. 

 

There’s a lot of math that happens when you design an experiment. Most of it revolves around eliminating the possibility that any results you have are actually due to random chance. I’m not going to delve deeply into statistics here, because honestly very few people find it super interesting (I do!) — but here’s an example of why it’s important to have a statistician involved when you plan your experiment. 

 

Let’s say I’m going to do a classic coin flip experiment. In order to decide whether the coin I have in my pocket is actually fair, I will flip it five times. My mind tells me that if I flip this coin and get five heads in a row, then the coin is obviously not fair, right? Probability tells me that about 3% of the time I’m going to get 5 heads in a row on 5 flips with a perfectly fair coin. This number – the probability that random chance has accounted for my results – is known as p.

 

And maybe for a coin flip, 3% (that’s a p of 0.03) is an acceptable chance to take. When people’s lives are at stake, researchers like their numbers to be a little more definite, so they involve a statistician to help design the test. In the coin flip above, if I expand my number of flips to 10, there is a 0.09% chance (for a p of 0.0009) that all 10 will be heads by random chance. That’s a much smaller number – and more on the scale of what we’re looking for. 

 

Pfizer and Moderna both released their interim trial data for symptomatic coronavirus infections (the thing the trial was designed to test) – and that data showed 94-95% effectiveness with a p <0.0001. That means that with regard to symptomatic infections, the numbers we are seeing are less than 0.01% likely to be due to random chance.

 

However.

Neither trial was designed (built specifically to eliminate outside factors) or powered (with the statistician involved up front) to look for asymptomatic infections. That means that any information coming out of those trials (and there is some) about asymptomatic infections is being done as a retrospective or “look back” analysis. There may be enough data to give us an answer (Moderna has submitted some numbers coming from the tests they administered at the time of second vaccination) but it’s never going to be quite as solid as the conclusions that the trial was actually designed to draw. 

 

That means – ultimately – we don’t know how well this vaccine protects against asymptomatic infections. And because up to 40% of infections in unvaccinated people are asymptomatic, that’s a pretty large “don’t know”. If you add that to the 5% of people (1 in 20) who are vaccinated who may still get infected, that’s enough wiggle room for a lot of viruses to slip through. 

 

I’ve been playing role-playing games since high school (if you hadn’t figured out by now what a huge nerd I am). 1 in 20 happens a lot more often than your brain tells you it should, even with the very best dice.

 

We still have a lot to learn. In order to save as many lives as possible while scientists take the time they need to learn it, I’m going to keep wearing my mask and keeping my distance. 

 

Just in case. 

 

Because every single one of you is that important to me.

 

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.

Nursing Home Day

Posted on by Dr. Nykki

 

An empty room in black and white

Empty Beds

I made nursing home rounds today. 

I am working through unpacking “long covid”, and also unpacking the reports of folks who did not sail through vaccine administration as smoothly as I did, but the absence of people for whom I was as familiar a face as their own families hit me unexpectedly hard, and I don’t have the words today. 

This is not a post about COVID vaccines, and it is a post about COVID vaccines.

I am thinking about my friend spending twelve and fourteen hours at a time in a moon suit, striving desperately to save people I can no longer manage as outpatients, whose tired eyes reveal the truth when she tells me “I’m fine.”

I am thinking about calling families to ask them if they want to come say their last goodbyes, or if they want me to keep fighting, knowing that if they choose to keep fighting then their goodbyes may have to be said by video chat, a long way from home. 

I am thinking about my office staff calling people every day at home. “How is your fever? Are you short of breath? Can you check your oxygen level?” and about the way sometimes we are the only contact people have in isolation. 

I am thinking about video chats from my living room late in the evening to decide whether a baby is sick enough to need admission, because life doesn’t happen during office hours, and about drive-by lung examinations the next day, just so we will both sleep better. 

I am thinking about life, and death, and about the glimmer of hope this vaccine represents to so many of my patients, who have lived their lives in isolation since the first thaws of spring this year.

They are counting on me. On us. On science. On the infinite ingenuity of humanity. 

There are too many empty beds already. And all we can do is all we can do.

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. 

 

 

 

 

A Brief Update

Posted on by Dr. Nykki

A Brief Update

 

Last night I went to sleep and didn’t get up until the next morning (h/t Arlo Guthrie). I still have no superpowers, other than the perfectly ordinary superpowers I’ve always had. I feel good physically.

 

It’s been a long day of catching up on things I’ve meant to do and it’s late. I’m going to keep this update short, because I haven’t had time to do my research properly. 

 

Questions for today, being pushed to tomorrow: 

  • If I have had Guillain-Barre syndrome in the past, is it advisable that I get the COVID-19 vaccine? 
  • If I am a COVID “long hauler”, is it advisable to get the vaccine? What if my early antibody tests were negative?

 

 

Dr. Nykki in her mask

 

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.