Vaccine Readiness

It is estimated that at least 70% of the population needs to be immune in order to begin to see significant herd immunity.  Currently, only about 50% of Americans are willing to get vaccinated.  At this point in time, we have 2 vaccines completing phase 3 trials with emergency use authorization pending.  Pfizer’s mRNA vaccine on 12/10/2020 and Moderna’s mRNA vaccine on 12/17/2020.  Both these vaccines have demonstrated safety and about 95% efficacy in preventing symptomatic disease and about 99% efficacy in preventing severe disease.  We have been told that once given authorization, they can be immediately distributed and ready to be given with 2 days.  The details of the distribution plan are not yet available.  Other vaccines will become available soon afterward.

Initial Distribution

The initial supply of the vaccines will be severely limited and with 50% of Americans willing to receive them, the demand will far exceed the supply.  Therefore, those that refuse the vaccine will not slow the initial effort to protect the country.  The limited supplies will be prioritized to health care providers and other front line workers at high risk of exposure and the elderly and those with co-morbidities predisposing them to severe disease and death from Covid-19.

Hidden Problem

Most companies have not yet begun studying the vaccines in children.  Children make up 25% of the population in the USA.  Although children are at statistically lower risk than adults for severe disease, they also can become seriously ill and die from Covid-19.  In addition, although they are less likely to become seriously ill, they are just as likely to become infected and spread the infection.  Because they are more likely to be asymptomatic or mildly symptomatic, they are an unseen, concealed danger to everyone.  The American Academy of Pediatrics recommends children under 2 years of age not wear masks due to concerns about interfering with breathing.  Adults do not normally isolate themselves from infants and children.  During office visits, my greatest fear is not taking a nasal swab from a possibly Covid-19 positive patient, but instead, examining an unmasked, crying, struggling infant or toddler who is spraying his respiratory secretions throughout the room.  I wear an N95 mask and face shield for those exams.  Vaccinating children for Covid-19 is not the first priority and current vaccine supplies are very limited.  I expect that by the time the vaccine supplies increase substantially, the studies on children will have been completed.

Mid and End Distribution

After the first 100 million doses of vaccine are given an increasing majority of the remaining people will be unwilling to be vaccinated.  Assuming the safety and effectiveness of the vaccines hold up following the initial mass distribution, what strategies are likely to work to allow us to achieve herd immunity? 

• The safety and effectiveness data need to be clearly communicated to the public.
• Comparison data of infection rates in contained groupings like nursing homes, prisons, hospital employees, police force, etc. before and after vaccination.

Guaranteeing Herd Immunity

I never cease to be amazed by how many parents don’t have their children receive routine child vaccinations because they want to protect the health of their children, but rather do it because it is required for school or daycare attendance.  The same holds true for hospital employees, many of whom would refuse influenza vaccine if it were not required for their employment.  Given that is “standard behavior” for our population I propose the following as examples of entities that should require Covid-19 vaccination for their employees:

• Hospitals
• Medical Offices
• Nursing Homes (employees & residents)
• Federal, State, Local Government employees
• Police departments
• Fire departments
• Schools (employees & students)
  • College
  • High School
  • Middle School
  • Elementary School
  • Preschool/Daycare
• Prisons (employees & inmates)
• Public Transportation (Even better if you include passengers)
  • Airlines
  • Buses
  • Boats
  • Taxis, Uber, Lyft
• Delivery Services (UPS, FedEx, Amazon, etc.)
• Gyms
• Restaurants
• Bars
• Personal Services
  • Hair Salons
  • Nail Salons
  • Tattoo Parlors

Until Herd Immunity is Achieved

In the meantime, while we wait to achieve herd immunity, we must do our best to prevent infection spread (Don’t Share Air):

• Avoid contact with people whenever possible
• Social distancing (6+ feet apart)
• Wear a mask if around people
• Meet outdoors instead of indoors if possible
• Wash/sanitize your hands frequently

Conclusion

Many questions remain to be answered:

• How long will immunity last for each vaccine?
• How long will immunity last following a Covid-19 infection?
• Will there be rare serious vaccine side effects found after we have more experience with the vaccines?

Achieving herd immunity is readily achievable, but only if we “put our foot down” and insist it be done.  As of this writing, Worldometer shows 266,016 people have already died in the USA of Covid-19.  We now have the tools to stop it.  Let’s get it done.

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Arnold Solof, MD

   ABC news today relayed a statement from WHO (The World Health Organization) “Globally, about 3.4% of reported COVID-19 cases have died,” WHO Director-General Dr. Tedros Adhanom Ghebreyesus said at a press conference in Geneva on Tuesday. “By comparison, seasonal flu generally kills far fewer than 1% of those infected.”

  The problem with this statement is the denominator which is “reported COVID-19 cases”.  

  We already know that the majority of even reported cases are mild illness and that the infection can, in some cases, be completely asymptomatic.  Until we test general population samples regardless of the presence of any symptoms we will not know how prevalent the virus is in our communities and what the true lethality rate is.

  Let me illustrate some points by comparing COVID-19 with other infectious diseases that have been well studied.  

  When the CDC reports about epidemics like Influenza in their publication MMWR (Morbidity & Mortality Weekly Report) they describe the clinical presentation in terms of percentages of cases with listed symptoms.  So, for example, a Flu outbreak study might reveal 80% of cases with fever, 70 % with cough, 75 % with runny nose, 25% with abdominal pain,  60% with body aches, 15 % with diarrhea,  25% with vomiting, etc.  Note that most cases will not have every possible symptom and that each case might have a different combination of symptoms, even though they are infected with exactly the same virus.   The percentages often vary in different subgroups, so, for example, children with Flu get gastrointestinal symptoms more often than adults and that an individual case might present clinically more like gastroenteritis than Flu.  

  So, considering the above, we have yet to fully define the clinical spectrum of COVID-19 because we are only recognizing the patterns we have already identified.   If COVID-19 were also to cause a greater gastrointestinal pattern in children compared to adults, and a COVID-19 infected child with predominently gastrointestinal symptoms presented to a physician for a diagnosis, it would not be identified.

  Consider the case of meningococcal infections.  Meningococcus is known & feared for causing extremely serious and potentially fatal infections of septicemia and meningitis.  However, outbreaks of meningococcal disease often consist of 1 to a few cases.  Meanwhile, in some of those outbreaks, more than 10% of some populations (eg. college students) could be carrying the bacteria silently with no  symptoms, spreading it around the community.  Only the few unlucky individuals who get the severe forms of the disease are recognized as having it.

  So I anxiously await studies/surveys of samples of the general population so we can get a much more complete and numerically accurate picture of COVID-19 and what we are dealing with.   My suspicion is that the lethality of the virus is much lower than what is currently being reported.  The above studies will provide the answers.

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Arnold Solof, MD

(The following is for general information purposes.  For specific cases, consult your doctor.)

About 1 out of every 6 children have some degree of asthma and in the majority of those it is mild and intermittent.  The time between flare ups is often long (months or years) and patients/parents frequently forget how they should use/time/sequence the medicines.  I’m writing this to serve as a quick reference/review/cheat-sheet for those that need this refresher following a long asthma symptom free interval.  Improper usage of asthma medicines will not only make the treatment less effective but may increase the risk of side effects, some serious including death.

Rescue Medicines

Common rescue medicines include albuterol and xopenex.  The inhaled forms delivered either by a metered dose inhaler (MDI) or nebulizer work quickly (within minutes) and generally last a few hours (4 – 6).  If you are having asthma symptoms currently they can provide relatively immediate relief.

Controller Medicines

Common controller medicines include:

• inhaled topical corticosteroids(fluticasone/Flovent & Arnuity Ellipta, beclomethasone/Qvar, budesonide/Pulmicort, mometasone/Asmanex),
• montelukast/Singulair
• long acting beta 2 adrenergic drugs  (salmeterol, formoterol)

Controller Medicines take a while before they start working.  Some may take a few days to a week before you see their full effect.  Often, especially the inhaled topical steroids, are much more effective in reducing and preventing symptoms.  They last much longer with effects that can persist sometimes days instead of hours.

Generally the inhaled topical corticosteroids are preferred because they work much better and have minimal side effects.  These should not be confused with systemic corticosteroids that are swallowed or injected which have a far greater potential for serious side effects.

Some patients do better with a combination of controllers:

• Advair (fluticasone & salmeterol)
• Symbicort (budesinide & formoterol)
• Dulera (Mometasone & formoterol)
• AirDuo RespiClick (fluticasone propionate & salmeterol)
• Using Singulair in addition to another controller.

When to Use Rescue Medicines

The most common rescue medicine currently used is albuterol by meter dose inhaler (MDI).  Common brands include Ventolin and ProAir.  However, the recommendations below are general to all rescue meds (eg. albuterol delivered by a nebulizer)

1. Rescue Medicine without Controllers

• For prevention of exercise induced asthma.  For those who only have symptoms with exercise and if their asthma frequently occurs with exercise, the symptoms can sometimes be prevented by using the rescue medicine a few minutes prior to exercise.
• Regardless of the trigger, for those whose symptoms are very infrequent and can be treated effectively with no more than 2 doses per week of their rescue medicine.

2. Rescue Medicine with Controllers

• Those taking controller medicines that are currently having asthma symptoms (cough/wheeze) should take their rescue medicine also.

When to Use Controller Medicines

• Controller medicines should be used during the block of time of an asthma flare up
• The block of time varies and could be days, weeks or months.
• A general rule of thumb is if you have to use your rescue medicine more than 2 times in a week you can consider this an asthma flare-up and you should start your controller medicine.
• The controller medicine can be stopped after the block of time of the flare up.
• You may need about 1 week of being totally free of symptoms (cough, wheeze) to be reasonably sure the asthma flare-up is over.
• If after stopping the controller the symptoms return, resume taking the controller.

Common Scenarios

• A person who has not needed any medicine for 6 months is exposed to paint fumes and starts to cough and wheeze.  One dose of his rescue medicine effectively stops the symptoms and the symptoms don’t return.  No furthur treatment is needed.
• During Spring pollen season, a child has just required his 3rd rescue medicine treatment within a week.  He should now start his controller medicine.  He should continue it until he has been totally symptom free for a least a week.  The rescue medicine can be given as needed for active symptoms while he is taking the controller medicine.
• A child has been symtom free and off medicine for 9 months.  He catches a cold and his asthma begins to flare.  He should start his controller medicine and continue it until he has been symptom free for 2 to 3 weeks.  Studies show that abnormal pulmonary function can persist for weeks following a cold in people with asthma. The rescue medicine can be used in addition, as needed, to treat active symptoms.  Generally, “Cold Medicines” can be cautiously used in addition to asthma medicines, if needed.
• A child who tolerates exercise most of the time begins coughing and wheezing during a soccer match.  The rescue medicine controls the symptoms and they don’t recur.  No furthur treatment is needed.

If the Medicines Aren’t Working Well

• Verify you are using the correct medicines and timing and sequencing them correctly as described above.
• Check to see you are using the doses prescribed.
• If using a mist type metered dose inhaler be sure you are using it with a spacer and using the correct technique.  Even adults get a fraction of the dose if they don’t use a spacer.  If it is a small child who cannot form a seal over the mouthpiece, use the appropriate sized mask with the spacer.  How to use an Inhaler with a Spacer
• If you are using a powder type inhaler, be sure you are using the correct technique. How to use:
  • Pulmicort Flexhaler
  • Asmanex Twisthaler1  Twisthaler2
• If you are using a nebulizer, verify you are using the correct technique.  How to use a nebulizer
• If your symptoms are not improving with the prescribed treatment or are getting worse, call your doctor.

I welcome any suggestions for improving this article.

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The Legacy of Autism and the Future of Neurodiversity

By Steve Silberman

Read by William Hughes

Review by Arnold Solof, MD  – Pediatrician

      I just finished listening to this audiobook.  I wasn’t sure what to expect, but the title accurately condenses the content of the book.  The audiobook is 18 hours long, and this reflects the depth to which the author’s study and analysis have gone to research the subject. 

     Steve Silberman is a journalist.  Given he is a journalist, I am very impressed with how accurately he has described the medical topics related to autism.  I did not find even one instance where he fumbled there.  On the other hand, I think not being a medical professional helped free his analysis from being encumbered by the limitations medical models, which to this date, fail to understand and explain the autism condition and its causality.

     This book reviews the history of autism from its first descriptions through to modern-day thinking and the competing theories that have occurred along the way.  It analyzes it from the psychiatric, parental, and the affected person’s points of views.

     The book concludes by considering autism more as “neurodiversity” rather than a disease and recommends a more inclusive approach of society to individuals with autism; benefiting from the associated strengths and abilities of autistic people and accommodating their special needs.

     After reading (or listening) to this book, you will not be an expert on autism, but you will come away with a much deeper understanding of the evolutionary history of this diagnosis, why we are seeing so many more individuals with autism nowadays and where we are (or should be) heading with this subject in the future.

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Arnold Solof, MD

I was listening to a politician commenting on the recent mass shooting in  Marjory Stoneman Douglas High School in Parkland, Florida.  He stated that we are medicating our children too much with drugs for ADHD and depression, implying that is was an underlying cause of the outbreak of mass shootings.

I’m thinking, “what planet does he live on?” Unless you are a recluse living away from civilization, deep in the woods, or up in a mountainous, snowy wasteland, you are living with people.  There is no shortage of “messed up” people on our planet.  I sometimes wonder whether overpopulation is underlying what seems to be a progressive underlying erosion of the moral fabric of our society.

Nikolas Jacob Cruz, was a 19-year-old former student at the school.  State investigators reported Cruz had depression, autism, and attention deficit hyperactivity disorder.

As a pediatrician, I take care of children of all ages.  Many of them exhibit “issues”/”problems” right from birth.  Sometimes they become apparent later in infancy or early childhood.  But, I can assure you there is a significant proportion of our population which has problems with mental issues.  The common ones are ADHD (Attention Deficit Disorder) and Mood Disorders such as Depression and Anxiety.  There is a smaller group who suffer from even more severe problems such as Conduct Disorder & Psychosis (eg. Schizophrenia).

There is a severe shortage of quality, available resources to treat people with these problems.  There are just too many people affected, overwhelming the system.  So, as a pediatrician, all but the most severe cases tend to get left to me.

So, what do I do?  Do I say “It’s out of my area of expertise” and refuse to treat them?  Or, do I learn the basics and offer the standard available treatments within the scope of my practice in a “best effort” to help them with their problems.

If you look at the available treatment options, by far the most effective and the ones with the “most bang for the buck” are medications.  Commonly stimulants (eg. methamphetamine/amphetamine) for ADHD and SSRIs (eg. Prozac, Zoloft, etc.) for depression).

When I think of the quantity of psychoactive drugs I prescribe I feel like a drug pusher.  I hate it when I look at it globally.  But, when I am treating an individual child or adolescent and I consider his/her options, I frequently come to a different conclusion.  If, by treating with meds, I can greatly improve the child’s learning and success in school and life; if I can improve his/her mood so as to not feel chronically depressed and suicidal; if I can improve his/her ability to interact socially with other people and successfully integrate into society, should I decline to do so because I am contributing to the proportion of children who are medicated?

Now repeat this situation patient after patient, day by day, year after year, and what have I done.  So, yes, I am guilty.  Guilty of having contributed to the number of children medicated.

These children are not medicated (or at least should not be) for frivolous reasons.  The fact that such a high proportion of our population have issues/problems that can benefit from the use of mental health treatments does in no way imply that those treatments are the cause the children’s problems or are responsible for the acts of dysfunctional people.

What to do?

Instead of blaming people attempting to do something about the lack of available mental health resources in our country we should be figuring out ways to make those resources better and more available.

The post My Fault, Really? appeared first on Arnold Solof.

Arnold Solof, MD

Belief Systems

People have certain trigger topics that upon hearing them initiate an automatic recall of not only a set of believed “facts” but a visceral set of associated feelings. Examples of this include God, religion, and abortion.  There are trigger topics in medicine as well.  Examples are circumcision and Flu vaccine.  Everyone doesn’t have exactly the same triggers or have them to the same degree, but the phenomenon is real and present.

So, in the case of Flu vaccine, when the topic is mentioned, a response is set off. The individual “knows” about it and “understands it”.  If the person happens to know incorrect facts, trying to correct or explain the error is like trying to negate the existence of God in a believer.  The person doesn’t want the correct facts and is unable to consider the possibility that the universe is different than they perceive it.  At this point, the veracity/reliability of the source of their current beliefs is irrelevant.  To them, it is known and accepted.  By the same token, the authority/knowledge of the new/alternate source of information is also irrelevant.  Having incorporated the facts/perceptions into their current belief system preempts all other considerations.

So, for people who “know” that Flu Vaccine:

• Is bad for them
• Will make them sick
• Will give them the Flu
• Is a conspiracy of the medical profession
• Is something they should not get and should not let their children get

It is more of a faith/religious-like belief system than a set of facts and scientific understanding promulgated by a reliable source of medical information with a convincing argument.

However, at times when the Flu hits particularly hard and is viewed repeatedly on the daily news cycle (like what is happening now), fear and panic set in and temporarily suppress this trigger-like emotional response system.  These people are getting the Flu Vaccine.  This is occurring despite the fact that this years vaccine is only about 1/3 to 1/4 as effective as the average annual Flu Vaccine and that it is mid-February and so perhaps we have 2 months remaining out of the total 8 Month Flu season (1/4 of the season).  This Flu season is especially severe.  There are far more cases than usual and we are seeing many more deaths.  It is roughly 4 times more severe than the average Flu season.

The Math

For those of you who haven’t gone to medical school and spent a lifetime contemplating vaccine administration strategies; for those of you who don’t automatically compute the odds of various risk scenarios in your head in an attempt to reach rational decisions, let me break it down for you mathematically.

We will estimate how many people out of 100 we will protect.

M = Months of protection

E = Efficacy

S = Severity

Current Flu Vaccine Situation:

• 100 X 2M/8M X .2E/1E  X 4S/1S = 10          (ie. 10 cases out of 100 prevented)

Standard (average) Season Flu Vaccine Strategy

• 100 X 8M/8M X 0.8E/1E X 1S/1S = 80           (ie. 80 cases out of 100 prevented)

What Will Happen?

Next year when the next average Flu season arrives and without the current panic/daily news cycle reminders, people will revert to their automatic triggers and belief systems.  It won’t matter to them if 1+1=2 if it contradicts their belief system.  They will assume the math must be wrong for some reason.  They will leave themselves and their children unprotected.

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Arnold Solof, MD

PrEP and PEP to Prevent HIV

Definitions:

• PrEP = Pre-exposure Prophylaxis
• PEP = Post-exposure Prophylaxis

PEP

It seems that not so long ago there was post-exposure prophylaxis for HIV, but we didn’t have good data on it to confirm that it worked or how well it worked.  We did it because it made sense and was the best we could do.  Now, this has been studied reasonably well and we have confirmation of its efficacy.  It is not cheap, but it is frequently covered by medical insurance or the liability policies of our employers.

So what are some examples of exposure that one would want Post-exposure prophylaxis?

1. think you may have been exposed to HIV during sex (for example, if the condom broke)
2. shared needles
3. were sexually assaulted

Detailed Information on PEP from the CDC

PrEP

Even newer is the development of protocols/treatments that prevent HIV before exposures to it.  It is also expensive but frequently covered by insurance.

What are some examples of situations in which you would consider Pre-exposure prophylaxis?

1.  Daily PrEP use can lower the risk of getting HIV from sex by more than 90% (eg. HIV Infected Sex Partner or live in an area with a high incidence of HIV)
2.  Daily PrEP use can lower the risk of getting HIV from injection drug use by more than 70%

Detailed Information on PrEP from the CDC

The drugs used have occasional side effects and some people may not be able to use them because of this.

Although not perfect, until we get an effective vaccine, it is a useful tool/option to have.

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Arnold Solof, MD

I was just reviewing information on methods to prevent HIV infection.  In a recent trial of a candidate vaccine, it was found to have “only” 30% efficacy in preventing HIV infection (so it was deemed not effective).  The presenter was a world-recognized specialist in pediatric infectious diseases.

Upon hearing that I recalled numerous reports over the past few months stating that the Flu vaccine for the 2017-2018 season was only about 10% effective (note: more recent estimates are around 33% efficacy).  Yet, the infectious disease specialists were recommending everyone get the Flu vaccine despite the believed 10% efficacy.  Their position was “10% is better than zero”.  I thought, Wow! 10%.  Whoopie!  I was having a hard time getting excited about that.

So, although both infections can kill you, given the choice, I’d take my chances with influenza before I would with HIV and I find it interesting how the efficacy assessments of these 2 scenarios seem reversed. I can’t help but think that in this case, the medical profession guilty of the same kind of prejudice we accuse our patients of when it comes to Flu vaccines.  Did we stop and think before we spoke?

HIV Vaccine Development

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The toxicity and public health devastation caused by both directly smoking cigarettes and inhaling secondhand tobacco smoke are well established and generally accepted.  The role of thirdhand smoke is currently under study and its harmful role to our health is just coming into focus.

Definitions:

• Firsthand Smoke = Directly inhaling smoke while smoking a cigarette, cigar, etc.
• Secondhand Smoke = Not smoking but inhaling the smoke left by others who are currently present or have recently been smoking at your current location.
• Thirdhand Smoke = The result of residual nicotine and other chemicals left on indoor surfaces by tobacco smoke.  This residue reacts with common indoor pollutants to create a toxic mix including cancer-causing compounds.  It is gradually released back into the air as a gas or travels in the air on dust particles.

You cannot see thirdhand smoke.  The visible smoke disappeared a long time ago.   However, you certainly can smell it.  For example, if you travel in a car whose regular driver smokes, not only do you smell it in the car, but the thirdhand smoke gets on you and people can smell it on you even after you leave the car.

On one hand, you may think that if there is so little of it you can’t even see it, how can it be harmful (besides stinking)?  The factor that magnifies its toxicity is the duration of exposure.  Exposure to secondhand smoke may occur over a course of hours, but thirdhand smoke exposure could last for years if it affects your house or workplace.

Evidence so far has shown thirdhand smoke:

• causes significant DNA damage in human cell lines
• causes oxidative based lesions has been confirmed in skin wounds of mice models
• causes metabolomic changes in human reproductive cell lines
• negatively impacts body weight in both male and female mice
• induces persistent changes to immunological parameters in peripheral blood in mice
• is genotoxic at realistic experimental doses
• may cause some other forms of cellular damage

Thirdhand Smoke: New Evidence, Challenges, and Future Directions

Adverse Health Effects of Thirdhand Smoke: From Cell to Animal Models

Arnold Solof, MD

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I was reviewing some information on menstrual irregularities and contraception and thought it would be helpful to point out a few things.  When choosing the best contraceptive method there are many factors to consider, but the first factor should be how effective it is.  After all, if it doesn’t work, what’s the point.  It is striking how much difference there is in the effectiveness of each method.

The following is a graphic from the CDC which briefly describes the various methods and their relative efficacies.  Click on the graphic to enlarge it.

In the past, there was more concern about using LARC (Long-Acting Reversible Contraception) in adolescents.  Over time and with improving products, this is no longer the case.  With their extremely high efficacy, minimal side effects, and relatively little need for intervention (like remembering to take a pill), they are considered “first-line” therapy in many cases.

Contraception Methods (CDC)

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