Village of Lawrence resident Dr. Mark Sicklick, an immunologist with a practice in Cedarhurst, offered his expertise in explaining the challenges being faced during the coronavirus pandemic. It was sent out by village officials.
Where are we at today, in mid-August?
Progress is being made on multiple fronts by multiple research groups. Vaccines seem to be in the headlines every day, and several are starting Phase 3 studies -- real world, real volunteers, getting what we hope will be a real vaccine.
None of us think that the Russian approach is safe. They did not do Phase 3 studies.
The end point of studies is to show real benefit to people, without significant side effects. It's not to find a positive laboratory result. It's not just about making antibodies. It's not just about making the T cells that kill the virus and boost antibody production. It is about modifying or weakening the disease in people.
One of the speed bumps that will slow everything down is that it is ethically wrong to give the vaccine or placebo to people and then deliberately expose them to the potentially fatal virus in order to see if the vaccine offers protection.
The risk with deliberate exposure is too high for the volunteers, especially for those getting the placebo. So, by default, the testing needs to be done on volunteers in high prevalence areas and we then look for a reduction in infectivity and morbidity and mortality in those getting the vaccine vs. those getting the placebo vs. those not getting anything. These enrollees need to be naturally exposed. Fortunately (if that's the right word), there are plenty of hot areas to work in.
Another issue will be actually getting the vaccine out for distribution and getting people to take the vaccine. In a world where, unfortunately, too many people don't wear masks and don't social distance, I fear that many people will not get a vaccine, no matter how safe and effective it is proven to be. This will leave us without herd immunity until too many people get sick. Some will die. Some will have permanent disability.
This is not different than the anti- smallpox groups when this country was very young, and the anti-polio vaccine groups, and the anti-measles groups, and all the other anti-vaxers. Time has shown how life saving these immunizations were, but history usually repeats itself.
The vaccines that are moving along have had some minor and some moderate side effects, ranging from local soreness and swelling to fever, chills, and aches. But the long term benefit appears to be there, at least in the early studies.
I am more optimistic about an earlier vaccine success than I was few weeks ago. I am amazed at how efficient the federal government has been in cutting the red tape and bureaucracy for the collective good. The president’s “Operation Warp Speed” is actually, despite my initial skepticism, working. The distance covered in a short time is unprecedented. This would have taken years under normal circumstances. We are getting closer. Federal money has been already released to mass produce the leading vaccine candidates so that if and when a vaccine is deemed to be beneficial, it will be available. The federal government has also ordered the production of glass vials and rubber stoppers to have them available when the vaccine is ready.
But remember that it is not happening tomorrow or next week or next month.
Also remember that the vaccine will not be 100 percent effective. It may only protect certain population groups or age categories. It may weaken the disease without stopping it. These results would nonetheless be beneficial. Even a suboptimal response to the vaccine will still lead towards herd immunity and to less hospitalizations and deaths.
Another important caveat is that this vaccine will likely not give lifetime protection. Repeat boosters made be needed yearly or even more often.
Not much has changed over the past few weeks. Optimal, to a degree game changing treatments, are a combination of anti-viral agents, anti- inflammatory agents, and blood thinners. (And less use of ventilators). We still need to learn which drugs of these classes are the most effective and least toxic, what are the optimal doses, what is the best timing for administration, and to know who benefits most from which drugs. Everyone is different.
One of my mentors was a physician in Bellevue in the 1940s when tuberculosis raged. A new drug, streptomycin, seemed to really help, but most eventually had a “relapse.” That was until someone found the optimal time course, which was one year, not three months. Finding the dose and timing of a drug, even one that will work, is very difficult and needs both insight and a bit of luck.
These classes of medications have already cut the mortality from what it was in April. The mortality rate, if you include those who were probably infected but never sought medical diagnosis, is probably under 1 percent. Of course, specific risk factors change this number in given populations. Also, because this virus is so contagious, even with a lower mortality rate, the absolute numbers of deaths will remain high. We don't know the real number of infected people since many don't seek medical attention and many others never get tested.
The drop in mortality from the early spring makes me feel somewhat more optimistic.
What to do now:
Individually, all of us with risk factors need to try to reduce those factors.
People with diabetes are in the high risk group. Diabetics need to control their blood sugars and follow instructions. Good enough under normal circumstances may not be good enough with Covid around. The higher the hemoglobin A1C is, the higher the risk.
Those who are overweight need to get into better shape. BMI (body mass index) tables are easy to find. A BMI over 30 is a risk for poor outcome.Over 35 has a higher risk of death. We all look in the mirror and see muscle. Very few of us are professional athletes with huge muscle mass that can account for a high BMI.
If someone has heart disease, lung disease, high blood pressure or any other medical problem that may or may not be linked to poor Covid outcome, these problems need to be addressed now.
As a corollary of this, many people are ignoring routine preventive medical care. This can lead to unnecessary deaths from other causes. Physical exams, immunizations, colonoscopies, mammograms, blood pressure checks, screening blood tests and follow up of known problems all must be done.
Collectively, we all need to reduce spread to others.
Masks (over the mouth and nose) and social distancing are the mainstay of virus containment. We all know this. Since no one knows if they carry or shed the virus even without having symptoms, we need to assume the worst and protect everyone. In the best case scenario (which is not a given), if those who have already have had Covid and have antibodies think that they can't get sick even when exposed (and, again, this is not proven to be true), they still may be able to be infected with the virus and spread it to others.
You're not being asked to shelter at home. You're not being asked to stop working. You're not being asked to stop schooling. You're simply being asked to wear a mask and to distance until a vaccine is successful. That's not asking a lot to save lives.
I do not understand people not wearing masks. I cannot comprehend how any groups can meet without masks. They are, even in the best of circumstances, potentially putting lives in danger.
For those who follow sports, everyone has been reading about the Florida Marlins. About half of the team has tested positive. These are young, healthy athletes. Most do not have risk factors that would make them more susceptible to disease. Yet the virus has run through them quickly. All it takes is one person to be shedding the virus to spread it to many people.
The take home lessons for all of us are that anyone can be spreading the virus and that anyone can be infected.
A few closing comments.
People coming from out of state need to quarantine. It’s really not a personal choice. It’s not a game to avoid detection. It's not about flying into a close, out of state airport and trying to evade the New York State quarantine rule. It’s about not endangering anyone else. People doing this are endangering other people.
In addition, I have become aware of some children who have returned from sleep away camps who have tested positive for Covid on their return home. Some were sick in camp and not tested. One camp nurse told me that their official camp policy is not to test anyone, no matter what. The positive children have said that other campers have had the same symptoms. This makes me worry about the influx of campers coming in a few weeks. Whether they need to be tested, be quarantined or have screening by a physician or all of the above needs to be decided. One local synagogue sent out an email mandating testing before returning to the synagogue from sleep away camp.
Finally, there have been parties. Some are large weddings, some are engagement parties, some commemorate a birth. Everyone has a reason. Many violate social distancing rules. On the videos that I have seen, some wear mask and others don’t. All of these are a step in the wrong direction and put lives in danger. Everyone needs to celebrate. Everyone wants to share happiness. It’s just not worth the risk to anyone at this time.
We all want to be at weddings, bar mitzvas, graduation parties and other celebrations. We don’t want to be at funerals.
I keep being told that “it is over.” It Isn’t. Cutting corners, violating rules that are there to save lives, and ignoring reality will lead to deaths. Look at the numbers across the country and around the world. How can anyone think that it's over?
The last three issues really concern me.