Type 1 Diabetes on the Rise : COVID Link

"A virus -- it could be just a cold -- puts stress on the body. We see this all the time. They [genetically pre-disposed children] have pre-diabetes for a period of months or years then they tip out [through an autoimmune response triggered by a COVID infection]."

"It's going to take us a few years to see if we have had a bump in the rate of diabetes. COVID-19 may have triggered that first bump."

"This is just one more reason for kids to be vaccinated."

"I want to reassure people. I'm not anticipating a huge spike. But we want parents to be aware of the symptoms and to bring their kids in [to see doctors] if they notice any of these [symptoms]. It needs to be monitored."

Dr.Sarah Lawrence pediatric endocrinologist, associate professor of pediatrics, University of Ottawa

"At this early point in time, the research shows an association between contracting COVID-19 and then being diagnosed with diabetes -- but there's no definitive evidence that shows new onset diabetes is caused by COVID-19."

This is very concerning and we must undertake  high-quality research to determine exactly what is happening with these youth and why."

Dr.Seema Nagpal, vice-president of science and policy, Diabetes Canada

Charles Muro,age 13, is inoculated by a nurse at Hartford Healthcare mass vaccination AFP via Getty Images

Studies of European children and youth during the pandemic have brought to light the occurrence of Type 1 diabetes diagnoses increasing along with increased frequency and severity of diabetic ketoacidosis at time of diagnosis. The result of undetected diabetes in children, bringing them to a dangerous level of approaching endocrine malfunction.  

 

Diabetes in adults could conceivably be connected to COVID-19 as a long-term consequence. As well the pandemic may have increased diabetes risk through increases in body mass index however indirectly, since this is one of the risk factors for both serious COVID-19 outcomes and diabetes.

The emerging realization of a connection between the coronavirus and diabetes onset in children has seen researchers and physicians urging parents of young children to be aware of diabetes symptoms in children who have been COVID-infected. All indications point to children being likelier to be newly diagnosed with diabetes a month or so following a COVID-19 infection, as opposed to those who hadn't been infected with the virus.

Findings corroborated by new research published by the U.S. Centers for Disease Control and Prevention. The CDC study authors have brought attention to health-care providers, urging them to screen for diabetes symptoms in children and youth who have been infected with COVID-19. To be alert to the classic symptoms of frequent urination, increased thirst, increased hunger, weight loss, tiredness or fatigue, stomach pain and nausea or vomiting, any of which symptoms could indicate diabetes onset.

 

Researchers with the Centers for Disease Control and Prevention (CDC) report that children who have recovered from COVID-19 may be at an increased risk of being diagnosed with diabetes. JDRF

 

Children and youth who had been diagnosed with COVID-19 in two American medical claims databases were the subject of the CDC study; IQVIA and HealthVerity, in the past two years. Claims of 80,893 young patients at IQVIA and 439,439 patient claims of youth at HealthVerity were reviewed for the study. Which resulted in identifying new diabetes diagnoses being 166 percent likelier to occur at IQVIA, and 31 percent more likely at HealthVerity among those who were infected with COVID-19 as opposed to the uninfected.

The researchers involved in the study found that patients under 18 years of age with COVID-19 were more likely to have new diagnoses of diabetes than those who had pre-pandemic acute respiratory infections. There is an expressed requirement to better understand the underlying causes, whether the COVID-19 infection, or treatment for an infection, the CDC study pointed out. Of interest is whether diabetes associated with COVID is transient or whether it will be chronic.

According to Diabetes Canada, diabetes prevalence among young people between the ages of one and 19 has increased. There were about 26,000 individuals between age one and 19 living with Type 1 and Type 2 a decade earlier. Type 1 diabetes, formerly referred to as Juvenile diabetes, strikes youth under 18 years of age, and the condition is insulin-dependent. Type 2 is generally connected to a sedentary lifestyle and overweight conditions, and can be controlled with drugs rather than insulin injections.

Dr.Lawrence, practising out of Children's Hospital of Eastern Ontario, recalls that when she began practising endocrinology in 1995, approximately fifty patients were diagnosed annually with Type 2 diabetes. Now the numbers hover around 120 cases yearly.

 

Administering a coronavirus test to Penelope Ramirez, 6, in Gardena, Calif.   Credit...Allison Zaucha for The New York Times

 

The Other Brazilians

Carl Court/Getty Images

"They have all they need out there."

"There are birds to hunt, and they have other food. There are seeds and insects and snakes they can eat."

Miguel Campos, 61, Brazilian boatman, Mangaratiba, Brazil

"I couldn't leave the cats out there in such a situation."

"I agreed to go the same hour [when she was shown a video from the island; Cat Alcatraz]."

Amelia Oliveira, Brazilian veterinarian

"It's terrible."

"Are we going to let the animals die of hunter, or are we going to keep on giving food, which will only incentivize more abandonment?"

Fernanda Porto, environmental sub-secretary, Mangaratiba, Brazil

Mangaratiba, Brazil

It is an island, uninhabited but for the cats that have been left there to fend for themselves over the years. The official name for the island is now Ilha Furtada. In popular nomenclature everyone refers to it as Ilha dos Gatos: Island of the Cats. It isn't known how the cats first appeared on the island. In the city of Mangaratiba, close by, officials say a family had attempted to make a life for themselves on the island decades earlier, but abandoned their plans and left behind a pair of cats. 

 

Boatmen have a different story, that there was once a restaurant on the island in a tourist area that closed, with the owners abandoning their cats to the island. It is one small island among many, on a island-hopping-tourism route, though not many have a wish to visit the island. It has no beaches, and large spiders are to be found there. And cats, hundreds and hundreds of cats, though the true numbers are not known. There is no source of fresh water on the island.

 

Locals had made it a habit to bring food to the cats. Animal lovers have defied the city asking people to stop feeding the cats, that it only encourages further abandonment. There is nothing on the island for the cats to eat. Most have become feral, many have been born on the island, and have no familiarity with humans, but among them are domesticated cats who were once someone's pet, and now roam the island just like the original abandoned cats. 

 

AP Photo/Silvia Izquierdo    Cats live on Furtada Island, popularly known as “Island of the Cats,” in Mangaratiba, Brazil

 

This long-standing problem of abandoned cats prowling a small island with no source of food or water has grown even more problematic over the past two years. Brazil is well known to have suffered greatly from the global pandemic. After India and the United States, it has the largest toll from COVID-19-related deaths. Over 465,000 people have died. With their deaths pets have found themselves without a home. Other Brazilians suffering from the economic downturn finding themselves impoverished without adequate sustenance for themselves, are no longer able to look after their pets.

Not only has Brazil been devastated by the coronavirus, its hospitals reeling from the stress of trying to cope with countless patients seriously ill from the SARS-CoV-2 virus, that other devastation -- of the country's pets left without care and affection and homes become homeless, wandering city streets desperately trying to adapt to scavenging for food and security. Shelters are unable to cope with the influx of abandoned pets.

The shelter located closest to the Island of the Cats has seen people arrive with car loads of cats, too many to take in all at once. When they decline they are informed "If you don't take them, they're going out to Island of the Cats". And this is precisely where they end up. People drop them off on the island or pay a boatman to make the trip, the last stop for unwanted cats who must learn to survive on their own and somehow manage to, aided by the food and water left by visitors. Some die.

 

 

 

Amelia Oliveira, a veterinarian who made it her business to travel around Brazil to care for animals found the island swarming with cats, some of which came toward her purring, and others who were totally feral avoiding her altogether. She has taken some of the friendly cats off the island preparing them for adoption; capturing and neutering others. Her organization has managed in the past ten years, to neuter 380 of the island's cats. "The cat population was being controlled", she said.

 

Volunteers and groups left food and water, set up small shelters. Local fishermen dropped off part of their catch. And then the pandemic hit and the delicate balance went off kilter as the cats swiftly increased in number. And those who had once fed the cats stopped leaving food and water when restrictions resulting from COVID were brought into law. The nearby city of Mangaratiba found itself with a larger problem needing a solution. 

 

The cat haven was nothing of the kind. It was a cruel solution to people no longer wanting to or able to care for their cats abandoning them to their own devices, live or die. People left jugs on the island to catch rain water. Cat food feeders were left there to be refilled on occasion. And cat-sized 'houses' dotted the island close to the water. Huge spider webs were strung out over everything. When people arrived the cats would congregate awaiting food, then slip back into the forest. 

 

Cat Island remains a problem, a blot on society -- awaiting a solution.

AP Photo/Silvia Izquierdo    Cats rest in the sun on Furtada Island, popularly known as “Island of the Cats,” in Mangaratiba, Brazil. 

 

Taming post-COVID Syndrome

"It seems like British Columbia is actually leading the country in this particular area, in supporting post-COVID. There are other clinics that are going to pop up, but I think B.C. is doing a pretty good job in terms of having a more structured network."

"They sound like pretty vague symptoms that we all experienced at times, but these have been quite debilitating and affecting people's lives."

"Frustration is probably one of the more common feelings that they experience. They also feel somewhat helpless."

"And that perhaps nobody's really listening to them."

Dr.Euseok Kim, medical director, B.C.'s latest post-COVID-19 recovery clinic, Abbottsford, B.C.

 

"I feel like everybody's doing literally the best that they can right now. But a lot of the things that long-haulers are experiencing, nobody really knows how to treat that."

"When you're living through it, you're just desperate for some kind of relief."

"Once we get through this acute crisis, we're going to have a lot of people who are still grappling with the chronic side of the pandemic. So it's vitally crucial that we do have these COVID care clinics."

"The level of disability for basic life function is pretty major right now. And I don't know when I will regain that. But I'm hopeful with the amount of research and science that is on right now, that we are going to find reasons and answers and treatments."

Katy McLean, 42, Vancouver resident

 

"Everything is piecemeal, and each province to its own. There's no continuity throughout Canada."

"There's not much available. There's one [clinic] in Windsor, there's one in London, but it becomes all so confusing. You have to hunt them down."

"It's moving in the right direction, but it's not going nearly as quickly as it needs to."

Susie Goulding, long-COVID victim, Oakville, Ontario

Dr. Angela Cheung is a senior clinician-scientist at University Health Network and is co-lead investigator on a study looking at one-year outcomes of COVID-19 patients. She says governments need to start thinking about the long-term impact of the pandemic. (University Health Network)

The most common symptoms that clinic patients present with are fatigue, brain fog, anxiety and depression. There are those among people who had undergone severe COVID cases, who suffer as well from organ dysfunction. The Abbotsford clinic that Dr. Kim operates has just recently opened. His colleagues, however, who work out of other clinics inform him that it is their experience that most patients begin showing signs of improvement following six to nine months of post-COVID recovery therapy.

 

 In British Columbia where COVID case numbers soared through the winter and following spring months, demand for post-COVID recovery clinics understandably increased. Two such clinics now operate in Vancouver, and one in each Surrey and Abbotsford, southeast of Vancouver. Those two are located in the Fraser Health Authority which happens to represent the hardest-hit area of the province.

 

An estimated ten percent -- more than 14,000 of the 142,700 people in British Columbia who were infected with the coronavirus -- were plagued with persistent symptoms. International studies put the number of COVID patients struggling with lingering symptoms of illness, from ten percent to close to one-third and up to as high numbers as three-quarters of those stricken with COVID, still suffering from post-COVID long-haul syndrome.

 

The first of the province's four post-COVID clinics, despite the expectation of numbers has dealt with fewer than 700 patients thus far. Katy McLean, one among the 700 patients, appreciates the screening tests given her at St. Paul's Hospital in Vancouver, and for the medical specialists and therapists whom she was referred to and who assisted in her recovery. She still questions the lack of services and resources devoted to the ongoing problems associated with COVID recovery, and people like her for whom that recovery has been prolonged.

 

Dr. Seema Marwaha, a general internal medicine specialist at Unity Health in Toronto, says the emergence of long-haul COVID-19 has exposed weaknesses in the health-care system when it comes to treating chronic conditions. (Supplied by Seema Marwaha)

Oakville, Ontario resident Susie Goulding has been coping with long-COVID for over  year in the face of too few publicly funded clinics operating in the Toronto area apart from the University Health Network services. She thinks in terms of a badly needed series of dedicated post-COVID clinics with the expertise to help sufferers and guide them toward a COVID-symptom-free future so they can resume their former lives, unhampered by symptoms that continue to incapacitate them.

 

She attends a private brain injury clinic outside the paid auspices of the universal health care system where her COVID symptoms, primarily neurological in nature, like crippling brain fog are treated. Memory loss, confusion and difficulty in focusing on a task all exemplify brain fog at its most frustratingly difficult. Although there are three post-COVID recovery clinics in Montreal, Sherbrooke and Chicoutimi, and Edmonton and Calgary operate several, the rest of the country hasn't seen fit to open such public medical clinics.

 

Petitions have been presented by several Members of Parliament urging the federal government to formally recognize long-COVID as a health syndrome requiring the establishment of countrywide clinics to address medical, rehabilitation and employment issues. The petitioners point out that "tens of thousands of Canadians" suffer from serious long-term symptoms affecting health, employment and day-to-day life. 

 

Before contracting COVID-19 in March 2020, Sonja Mally could hike for 10 hours. Now that she suffers debilitating symptoms as a COVID-19 'long-hauler,' she has spent months training her body to tolerate two-kilometre walks near her home. (Sam Nar/CBC)

COVID Convergence Mutations

"[I'm struck by the] amazing amount of convergent evolution we're seeing [with SARS-CoV-2]."

"There are these infamous mutations -- E484K, N501Y, and K417N -- which all three variants of concern are accumulating. That, added together, is very strong biology that this is the best version of this virus in the given moment."

Wendy Barclay, virologist, professor,Imperial College London

"If you wanted to sort of write a little textbook about viral evolution, it's happening right now."

"If it keeps happening over and over again, it must be providing some real growth advantage to this virus."

Dr.Francis Collins, geneticist, director, U.S. National Institutes of Health

"It's shown a very strong set of opening moves."

"We don't know what the end game is going to look like."

Vaughn Cooper, evolutionary biology specialist, University of Pittsburgh School of Medicine

National Institutes of Health Director Francis S. Collins holds a model of SARS-CoV-2, the novel coronavirus, as he testifies on Capitol Hill in Washington, D.C., U.S. Graeme Jennings/Pool via REUTERS/

 

Perhaps it's just too much to hope for at this junction that the novel coronavirus is mutating itself out of the realm of viral pathogenic superiority. It's as though a contestant for the worst-killer-virus-in-history is given just so many moves to improve its game, and it's making the wrong choices, and compounding them in an effort to become more deadly, whereas the process it's undergoing is beginning to mute its morbid effects on its human hosts.

Spike protein of SARS-CoV-2

The new variants that were detected in geographies far from one another, such as Brazil, South Africa and Britain mutated spontaneously within a short time-frame late last year, where all three share some similar mutations located in the vital 'spike' region of the virus, enabling it to enter and infect human cells. The E484k mutation, that some scientists familiarly named "EEk" for its capacity to evade natural immunity from previous COVID-19 infections while reducing protection offered by current vaccines, which is designed to target the spike protein, is included.

Similar mutations independent of one another have been appearing in various parts of the globe, indicating that the coronavirus is in the process of undergoing "convergent evolution", according to a number of scientists Reuters has interviewed. With expectations that the coronavirus will continue to mutate, immunologists and virologists now suspect that the coronavirus may be exhausting the fixed number of moves its evolutionary cycle allows.

If such is actually the case, the long-term impact for its survival remains to be seen, based on whether a limit exists on the number of possible mutations it can attain to, making it less dangerous. "It is plausible that this virus has a relatively limited number of antibody escape mutations it can make before it has played all of its cards, so to speak", explained Shane Crotty, a virologist at the La Jolla Institute for Immunology, San Diego.

That being the case, drugmakers could be enabled to remain current with the virus, developing booster vaccines meant to target current variants directly, even as governments struggle to control a pandemic that has succeeded in killing close to three million people globally. Experts have been mulling over the theory that the virus could be imbued with a limited number of mutations since early February, and it has gathered momentum since a paper was published showing the spontaneous appearance of seven variants in the United States alone, all appearing in the same region of the spike protein.

The very process of different species independently evolving like traits to improve survival odds represents the core of evolutionary biology. The current pandemic represents an evolutionary process scientists have been able to study in real time through the vast scope of its impact, with 127.3 million global infections. No pathogen in history has ever evolved within a comparable global scrutiny as has SARS=CoV-2.

This coronavirus in particular is not held by scientists to be particularly 'clever'. It is programmed by nature to replicate itself every time it infects people. Each copy the virus produces can be flawed in its exactness to the original. Some of these inexact copies may be one-time occurrences, while those that render a survival advantage to the coronavirus have a tendency to persist. And before compromising its fitness or changing so much it is no longer the same virus, leads some specialists to believe the virus may have a limited number of mutations available to it.

"I don't think it's going to reinvent itself with extra teeth", Ian Jones, a professor of virology at University of Reading in Britain, added. "If it had an unlimited number of tricks ... we would see an unlimited number of mutants, but we don't", observed Michael Nussenzweig, immunologist at Rockefeller University in New York. 

However, predicting how a virus will mutate is challenging. Should there be limits on how the coronavirus could evolve, matters would certainly be simplified for vaccine developers. As an example Novavax Inc. is in the process of adapting its vaccine specifically to target the South Africa variant which appeared to render current vaccines less effective, in laboratory tests. According to chief executive Stan Erck, the virus is capable of so much change only yet still binds to human hosts. The hope is that the vaccine would "cover the vast majority of strains that are circulating". 

Data-sharing platforms like the Global Initiative on Sharing Avian Flu Data is enabling researchers to track the variants through its huge trove of coronavirus genomes. Recently, scientists identified seven U.S. coronavirus variants with mutations occurring in the same location in a critical portion of the virus representing additional evidence of convergent evolution.

Experiments exposing the virus to antibodies in an effort to force it to mutate are being carried out by other teams of researchers. The same mutation in many cases appeared as a result, including the infamous E484K. Helping to raise cautious optimism that mutations appear to share many of the same traits, even as tracking changes in the virus must continue to choke off its ability to mutate by reducing transmission through vaccinations and other measures taken to limiting the virus's spread.

Scientists at Duke University sequenced positive coronavirus tests to identify which strains are circulating in the community, on Feb. 3.Credit...Pete Kiehart for The New York Times

AstraZeneca in Real Time

 "NACI [Canada's National Advisory Committee on Immunization] has determined that there is substantial uncertainty about the benefit of providing AstraZeneca COVID-19 vaccine to adults under 55 years of age, given the potential risks associated with it."

"As a precautionary measure, while Health Canada carries out an updated benefit-risk analysis based on emerging data, NACI recommends that the vaccine not be used in adults under the age of 55 years."

Dr.Shelley Deeks, vice-chair, National Advisory Committee on Immunization, Canada

"The [European Medicine Agency] still considers this product to be safe and effective, but the possibility of a link between the vaccine and clotting issues ... cannot be completely ruled out at this time."

Quebec Department of Health

An Iraqi nurse holds a vial of the AstraZeneca COVID-19 vaccine before starting the vaccination at a clinic in Baghdad, Iraq, Tuesday, March 2, 2021. (AP/Photo/Hadi Mizban)

 

Symptoms of potential serious side effects that may reveal the presence of blood clots are shortness of breath, chest pain, leg swelling, persistent abdominal pain, sudden onset of severe or persistent headache or blurred vision and skin bruising elsewhere than the site of vaccination, developing between four to 20 days following vaccination.

New data originating out of Europe suggesting the risk of blood clots now stands as potentially elevated as one in 100,000 representing a figure of risk substantially higher than the one in one million risk believed to exist in an earlier assessment of the AstraZeneca-Oxford vaccine has moved Canada's National Advisory Committee on Immunization to advise Canadian provinces to suspend their use of the COVID-19 vaccine produced by AstaZeneca.

AstraZeneca was asked by Health Canada on Monday to proceed with a detailed study on risks and benefits of its COVID-19 vaccine across multiple age groups even as the advisory committee recommended use of the shot be suspended until such time as an appropriate review has been achieved and its results studied. Most patients in Europe who developed a rare blood clot following vaccination with the AstroZeneca vaccine were women under age 55. They saw a fatality rate of 40 percent.

A change in advice has renewed apprehension around the AstraZeneca vaccine, which has been compounded by contradictory messages in Ontario. There’s also concern the confusion will add to vaccine hesitancy.

 

There have been no reports of blood clots occurring in Canada with the use of the AstraZeneca vaccine leading Health Canada's chief medical adviser, Dr.Supriya Sharma to declare she retains belief in the vaccine's benefits to outweigh any risks that may be inherent to its use. Health Canada changed the vaccine label to warn of the rare risk of blood clots developing with its use. 

 

Provincial governments take their own initiative on how a vaccine may be used. However, Dr.Howard Njoo, deputy chief medical officer of  health in Canada, revealed that all provinces and territories had reached agreement to suspend the vaccine's use for people under 55, while awaiting the results of further study.

Quebec, Manitoba, Newfoundland and Labrador and Prince Edward Island have announced their intention to limit the use of the vaccine. Taking a precautionary measure, Quebec's Health Department affirmed pausing the vaccine's use for its under-55 population, acknowledging the necessity of ruling out any possibility of a link to the development of blood clots with AstraZeneca.

Some adverse symptoms in younger people were noticed in the United Kingdom according to the medical lead of the province of Manitoba. "This is a pause while we wait for more information", explained Dr.Joss Reimer. Newfoundland and Labrador along with Prince Edward Island agreed they were pausing use of the vaccine for younger age groups as they wait for the new data expected to result from greater scrutiny in varied age groups being tested with the vaccine.

 

A medical worker receives a dose of the AstraZeneca vaccine in Taipei, Taiwan, on Monday. (Ann Wang/Reuters)

After AstraZemeca's vaccine was approved by Health Canada for all age groups, NACI observed enough seniors were not included in clinical trails to gain confidence on how the vaccine would perform on people over age 65. NACI then retracted that advice, claiming that new real-world evidence from the U.K. showed the vaccine was very effective in performance, used on seniors.  

"What we need to have is continued confidence in our expert review panel that it's looking at these vaccines and deciding what is going to be best, safest and most effective for Canadians."

"This is a new vaccine to a new virus, it's really important that we're following all the data as closely as possible and as the vaccines are rolling out, we're understanding them more and reviewing what the guidance should be."

Alyson Kelvin, virologist, Canadian Center for Vaccinology, Halifax.

The National Advisory Committee on Immunization (NACI) updated its guidelines against the use of the vaccine for younger Canadians on Monday. (Dado Ruvic/Reuters)

COVID Re-runs : One Vaccine Dose or Both?

"Somebody who has had COVID before seems to respond very quickly to a dose of vaccine. They respond as a naive person would with their second shot." 

"The question that remains is that a one-size-fits-all for every previous infection? If you were asymptomatic at first infection, is it still OK?"

"Will the response to a first dose of vaccine be the same for everybody who has had a COVID infection before, regardless of the severity of disease?"

Dr.Caroline Quach-Thanh, pediatric infectious disease specialist, co-chair, National Advisory Committee on Immunization, Canada

"There's certainly the suggestion that if you have previously been infected, it's kind of like having had your first dose [of vaccine]."

"[Reinfection can happen] It's not as rare as people think [and mutations are increasing the risk such that people who have contracted COVID before should be vaccinated]."

"[For younger people, a one-dose strategy may be a reasonable approach] but I think we need more data."

"For older people, I think it's really unknown, and I think assuming you could get away with it is probably not necessarily so wise."

Dr.Andrew Morris, infectious disease specialist, Toronto

Credit: iStock, Bill Oxford

 

In Canada, its premier national expert immunization advisory group is in the process of deliberating whether one dose of vaccine only may be sufficient protection for those people who have already experienced a bout of COVID-19. Recently, a few small studies appear to conclude that a single dose of the Pfizer/BioNTech and Moderna vaccine could be useful in creating a rapid immune response in people who have previously been infected with the coronavirus.

People with a known history of having had COVID report more vaccine side effects -- including fever, headache, chills and muscle and joint aches -- than the never-infected, following the first dose. The second dose generally tends to be more intensely prone to side effects. It remains unclear whether a single dose would gain sufficient protection for older people who were infected previously, or those people with compromised immune systems.

France's elite health authority recommends a one-dose-after-COVID strategy,  a recommendation that the province of Quebec has picked up for its effect in stretching vaccine supplies in this initial period of short supplies. The thought is there that while people appear to tolerate the vaccines, a single dose might also spare people unnecessary side effects by withholding a second dose, according to researchers.

It was found by one small study that following the first dose of a Pfizer or Moderna shot antibody titers -- meaning the amount of antibodies appearing in an individual's blood -- of those previously infected were seen to be ten to 46 times as high as those people being vaccinated who had no previous immunity after the first dose. They were 25 times as high 13 to 15 days following the first dose. Antibody concentrations of people never infected increased by a factor of 3 following the second shot "no increase in antibody titers was observed in the COVID-19 survivors who received the second vaccine dose" researchers from the Icahn School of Medicine in New York concluded, as they suggested a booster or second dose might offer little value.

Messenger RNA vaccines such as the Pfizer and Moderna models work by instructing the body's cells to produce a bit of the spike-shaped protein on the virus's surface, causing COVID. An immune response is then triggered to which the body responds by producing antibodies to protect against infection in the instance of the real virus entering someone's body. Once primed by a past infection to recognize the spike protein, the immune cells respond more vigorously following the first vaccine dose.

However, it is not yet understood how long those early differences in immune responses might last, much less whether older people would respond similarly. Nor how long a time the vaccine-based immune response would be effective. The advisory panel's controversial decision early in the month to recommend spacing shots out to up to 16 weeks in the interests of having more of the population vaccinated at least once places the new question into "less of an emergency situation to tackle."

Irrespective of which, according to most experts, booster shots are expected to represent the norm for the future which would see the regularization of annual vaccines to counter the coronavirus's anticipated season return and ongoing mutations. The Mount Sinai researchers suggested that people be screened for the presence of antibodies should infection history be unknown. Here too there are disagreements taking into account that people could have lower antibody levels following a COVID infection if they experienced mild or no symptoms at all.

Out of Denmark a larger study suggests that prior COVID infections endow people with up to an 80 percent protection rate against reinfection. There is, however, an age differential where people 65 and older were seen to have only a 47 percent protection against reinfection. 

A nurse supervisor prepared a dose of the Pfizer-BioNTech vaccine at a mass vaccination site in Hartford, Conn., this month.   Credit...Christopher Capozziello for The New York Times

But Was There Any Other Choice?

"All you have to do is look at the places that have had big lockdowns."

"You can see that the peak in the number of cases is a few days after the lockdown, and then the cases just keep dropping."

"There's no easy answers. No cheap, magic bullet."

Dr.Mark Jit, epidemiology professor, London School of Hygiene and Tropical Medicine, United Kingdom

"We must open up society to save many more lives than we can by attempting to avoid every case [or even most cases] of COVID-19."

Dr.Ari Joffe, critical care physician, University of Alberta

"This is not to deny the terrible health outcomes of COVID-19 infections."

"Among my patients, however, the acute challenges created by lockdowns are much more apparent."

Dr.Sonia Malhotra, family physician, Toronto

Scientists are scrambling to work out what effect specific measures, such as social distancing, have in slowing the spread of COVID-19.   Credit: Ivan Romano/Getty

When the novel coronavirus struck it was with a vengeance. Governments and their health advisers knew they were facing a strange new threat. The immediate reaction was to go into stark defensive mode; lockdown. Not universally by any means. It was the reactive position of Chinese authorities, where the SARS-CoV-2 virus first struck, to isolate and issue stern orders to remain in situ. And most countries did the same once the virus infiltrated their negligible defences. Those that did not, hoped to save their economies while trusting their populations to exercise the care of physical distancing. 

Since then, a year has brought millions of deaths attributable to the effects of COVID-19, hospitals and health personnel stretched their limits, and national economic meltdowns. Society has been left to pick up the pieces of shuttered-for-good businesses, ailing economies, high unemployment, fears of food scarcity, and the need to stretch state treasuries in an effort to cushion the blow both for government and business enterprises. And in support of families facing financial desperation.

Through it all, the mental and physical side effects of the coronavirus, the billions that governments have had to shovel out, the businesses hanging on by a thread of hope, medical experts remain uncertain just what reaction was the right choice universally. Dr.Joffe of the University of Alberta published a paper arguing the lockdowns to curb the spread of COVID resulted from 'group-think' not rational decision-making, he argues in the journal Frontiers of Public Health.

However, orders to restrict human-to-human contact has its champions and they are legion; the fact is, this is what has worked to set back the spread of the virus. It alone stands out as the most singular weapon in the 'non-pharmaceutical interventions' (NPIs) playbook of government-enacted COVID-preventive orders, according to Peter Klimek, a Medical University of Vienna, Austria physicist. It has been, in fact, policy combinations; border restrictions to banning gatherings, that succeeded in curbing cases.

Early preventive actions the key to long-term or repeated lockdown avoidance according to his research. "If you wait for too long, you have to use higher and higher measures to gain control of the situation." University of Greenwich, England researchers reviewed 348 other studies to discover them to "universally show" the importance that NPIs have in pausing the spread of COVID-19.

 

South Korea both controlled case numbers and deaths, permitting its economy to remain open, by and large; a study estimates infections would have exploded 27-fold in the early stages of the pandemic had the country not taken strict counter-measures which succeeded. There is no hard-and-fast formula however; whether to order people to remain at home or wear masks in public spaces, according to a University of Toronto epidemiologist, and head of the Centre for Global Health Research, Dr. Prabhat Jha. 

 

The journal Nature Scientific Reports published a Brazilian paper recently where head-to-head comparisons were made between similar places globally which in the view of the authors were either 'controlled' or 'uncontrolled' when respect to ensuring populations were ordered to remain within their homes. No evidence surfaced that lockdowns reduced numbers of COVID deaths per capita, according to the scientists. Peculiarly enough Australia -- with among the lowest death rates from COVID in the world -- was rated by the study as uncontrolled. 

 

Yet Australia imposed strict measures including hard border closures, mandatory hotel quarantine for arriving travellers and targeted lockdowns, while avoiding long-term stay-at-home orders. Then there is Florida where relatively few social restrictions were imposed and where the per-capita death rate is 2.5 times higher than Canada's following a series of lockdowns reflecting its 'controlled' designation.

Dr.Jlt and his colleagues had a paper published in the journal BMC Medicine which studied 130 countries by comparing their COVID strategies in the first months of the coronavirus to the rise and fall of cases, concluding that closing schools and restricting internal movement of people resulted in a strong effect on halting the spread of the virus, along with shuttering workplaces and providing income support to those whom the measures affected.

Researchers from Oxford University published a study in the journal Science verifying that eliminating small gatherings, closing non-essential businesses and restricting the size of family get-togethers headed a list of measures taken in over 200 countries slowing the virus's transmission. Including imposing border restrictions, increasing mask use and closing educational institutions. 

Hong Kong and Chinese academic researchers studied 190 countries in the pandemic's early stage suggesting that social distancing with school closures, restricted restaurant use, and shutting non-essential businesses were the most effective in restraining the virus contagion. Yet it is undeniable that these measures, while meeting the virus head-on working to slow its advance, came at a steep price, reducing peoples' emotional and financial well-being in the process.

According to Dr.Malhotra, lockdowns contributed to social fatigue, an emotion that has continued to grow as the situation wears on and a third wave headed by mutated viruses producing variants that surfaced in the United Kingdom, South Africa and Brazil have continued to take a heavy toll. Too little attention, she contends, has been given to the health impact of "blunt, sweeping" containment tactics.

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Catholic Bishops: Use of "licit" Vaccines

  AstraZeneca vaccine Photo: Jack Boland/Postmedia

"When ethically irreproachable COVID-19 vaccines are not available [e.g. in countries where vaccines without ethical problems are not made available to physicians and patients, or where their distribution is more difficult due to special storage and transport conditions, or when various types of vaccines are distributed in the same country but health authorities do not allow citizens to choose the vaccine with which to be inoculated] it is morally acceptable to receive COVID-19 vaccines that have used cell lines from aborted fetuses in their research and production process."

The Congregation for the Doctrine of the Faith, Vatican

"Since there is currently no choice of vaccine being offered, Catholics in good conscience, may receive the vaccine that is available and offered to them."

"These questions [over a different line of human embryonic cells from a different fetal retina] are important for they concern the sacredness of human life and its inherent dignity."

"Catholics are invited to be vaccinated, both in keeping with the dictates of their conscience and in contributing to the common good by promoting the health and safety of others."

Canadian Conference of Catholic Bishops clarification bulletin

The AstraZeneca-Oxford vaccine was developed using a cell line derived from fetal human embryonic kidney cells. (Dado Ruvic/Reuters)

 

Methods involving a line of cells known as HEK293 ("human embryonic kidney") led to the development of the AstraZeneca vaccine at Oxford University. The cell line is in wide use universally in science, biotechnology and pharmaceuticals, originally derived from a healthy female fetus around 1972. Frank Graham, Canadian pioneer of molecular virology was one of the scientists involved in the development of embryonic cells used as a technique in testing the behaviour of genes.

His involvement in the development of HEK293 took place initially in the Netherlands. Eventually he brought his ongoing research to McMaster University in Hamilton where he is professor emeritus. The cell line has been in wide use in the study of the expression of virus genes in vaccine research and development. The cell line itself has, since the original cells were obtained, divided countless times. 

In 2001 the leading scientist in the development of the cell line informed regulators in the U.S. that the reason or cause of an abortion which provided the fetus used was no longer available, records had been lost, but the assurance was that it had been a normal fetus, its family history unknown. The Catholic Church is concerned with the constituents of the virus since it is opposed to abortion even though there is no evidence available that the fetus had resulted from an elective abortion.

 

A woman receives communion during mass at the Mary Queen of the World Cathedral in Montreal, Que. The Canadian Conference of Catholic Bishops has urged parishioners to steer clear of viral vector vaccines like the one produced by AstraZeneca. (Graham Hughes/Canadian Press)

 

Johnson & Johnson's vaccine used the PER.C6 cell line, different, but still a line of human embryonic cells from another fetal retina. The knowledge that human fetal cells were used in the vaccine production prodded the Church to its advisories raising questions about the acceptability of the vaccines. When the original Vatican statement was circulated it caused confusion until the clarification followed.

The clarification was deemed necessary for the comfort of the faithful, following the confusing din over the original statement that Catholics should 'prefer' the Moderna and Pfizer vaccines because although "unethically-derived" cell lines may have been used in the final testing, the connection to abortion is "extremely remote"; say at a time-distance of a half-century and uncounted numbers of transformations over the years that followed.

AstraZeneca and Johnson & Johnson vaccines developed, produced and tested with cell lines originally from from human fetuses. Catholics were informed they should reject these vaccines as long as alternates were available, then reversed themselves in the following days to offer that Catholics may "licitly" receive any vaccine approved by Health Canada.

 

Nuns listen as Pope Francis delivers his blessing as he recites the Angelus noon prayer from the window of his studio overlooking St.Peter's Square, at the Vatican on June 7, 2020. Pope Francis is cautioning people in countries emerging from lockdown to keep following authorities’ rules for COVID-19 contagion containment. Says Francis: “Be careful, don’t cry victory, don’t cry victory too soon.”   Andrew Medichini / AP

The Holy Grail of COVID Vaccination

"We have to put away that idea that our value to society has anything to do with where we are on the priority list. If you're in a priority group for whatever reason, you can't say 'Skip me for now and give my dose to someone who needs it more."

"[There's a constant refrain from young and middle aged staff members] don't vaccinate me. Give it to my 77-year-old mother." 

"[Providing inoculation to essential caregivers as priority groups means an [iron ring] is developed protecting long-term care residents and personal care workers]."

"There's a lot of consistent data that vaccination prevents you from getting sick and dying of COVID. And there's a substantial drop -- about 75 percent -- in  your ability to transmit the virus."

Dr.Gerald Evans, chair, division of infectious disease, Queen's University

Anil Reddi has been allowed back inside his mother's care home to help feed her but only because she stopped eating. (Submitted by Anil Reddi)

"[Getting vaccinated was] emotionally complicated. I wonder if my acceptance of the vaccine takes it away from someone who would have worse outcomes if they contracted the virus."

"My main role on the hotline was advising callers about when and where to seek care. The guidance and protocols we’d been given were simple. Given capacity constraints in New York City, covid-19 tests were only being offered to people sick enough to need hospital admission. Thus, in guiding the callers, we were to screen people for dyspnea over the phone. I would listen to the story of each caller and assess their breathing, and tell them: if you ever feel short of breath, seek medical care immediately. Otherwise, stay home."

"But, as more evidence has emerged on covid-19, it appears that hypoxia caused by the virus doesn’t necessarily make people feel short of breath even if their oxygen saturations are dangerously low. People who may need medical intervention may not actually be dyspneic."

"In retrospect, I can’t help but wonder: did the advice I and other volunteers gave—to stay home unless severely symptomatic—cause unintended morbidity and mortality? Were there people I spoke to who should have presented to a hospital earlier, and would they have had better outcomes if they had? What about the other symptoms I didn’t discuss with them: how many patients had electrolyte derangements from diarrhea? Or strokes with neurological features I never warned them to look out for? Data suggest that many people in New York died at home —and that they were disproportionately from black and minority ethnic groups. I was following guidelines, but even so, did I ever inadvertently exacerbate these inequalities by telling some of the most vulnerable people not to seek care?"

Dr.Eric Kutscher, New York ICU physician, opinion piece, British Medical Journal

Regrets, guilt, second-guessing, overwhelming emotions; feelings of helplessness. Emotions felt by everyone for a variety of reasons; from people in the medical profession checking back on their recent memories and wondering why or if they could have or should have done things differently with the limited information on hand in trying to cope with the fallout from a new, voracious, threatening and harmful virus about which very little was known.

To the ordinary person feeling afflicted and fearful over the spread of the SARS-CoV-2 virus that news stories focus on, particularly the unknowns and those unfortunates who died in droves and others, post-COVID still suffering symptoms, much less the findings of its destructive capability on the body's internal organs. Everyone wants to be vaccinated to augment their body's immune system resistance against the dread foreign invader. Vaccine rollouts reflect the amount of doses available through the few pharmaceuticals that have succeeded in creating a safe and effective COVID vaccine.

And those scarce doses are being carefully husbanded as medical committees and governments at every level consider which are the most vulnerable populations to be prioritized for early vaccinations. Front-line medical workers, of course. The elderly and health-compromised living in long-term care institutions and retirement 'residences'. Those with chronic diseases that make them more vulnerable to the effects of the virus. People in low-income, disadvantaged circumstances; ethnic groups known to be more vulnerable.

 

Naila Shah, 60, is a resident at Seven Oaks long-term care home. Before the pandemic, her family visited twice a day to help with her care. (Submitted by Shah Family)

 

And there are some groups who are surprised when they are informed they are considered to be priority. They are younger, healthier than the conventional target groups yet they are persuaded that they belong, through circumstances among those prioritized for inoculation against COVID. They know that there are many, many others awaiting the psychological relief and the physical protection awaiting them once they've been vaccinated; people whose age and health dictate logically that they be vaccinated before the younger, hale demographic.

Those making the decisions about who comes first and who can wait, know that lives hang in the balance, linked to how they decide and who they decide must be first in line. It is well enough known that vastly disproportionate numbers of deaths have occurred among elderly residents of long-term care homes and retirement residences -- about 70 percent of deaths. It is logical that they must be inoculated before others less needful of protection. Just imagine the surprise when family members of the elderly in long-term care homes are given consent forms to sign, not only on behalf of their elderly relative, but themselves.

They are considered to be essential caregivers. And essential caregivers; basically family members who were accustomed to attending the care facilities on a frequent basis to give personal touches of care to their elderly family members some of whom suffer from various forms of dementia and cannot recognize their sons and daughters, are 'essential caregivers', slated for early vaccination at the very same time their elderly relatives are. That too seems logical and needful, until the rest of the story is absorbed.

That since long-term care homes and residences became hotbeds of COVID-19 infections and highly contagious, all family members, those who visited only occasionally and those who devoted hours upon hours of personal care to their elderly in close personal contact, have not been permitted entry physically to the premises holding their parents. It has been a year since visits have been out of bounds. Although communication can be made waving hands at one another through closed windows. Or speaking on cellphones. Or personal care worker-assisted Zoom calls.

Physician Burnout Versus Incoming Student Idealists

Medical school applicants Photo by Gustavo Fring, Pexels

"We're consistent with across the country and across North America, with what has been observed this cycle, which is a 20 percent increase in the number of applications."

"They see these individuals as people that have, you know, skill sets and things to not only save lives, but also are people that are willing to sacrifice for the greater good."

"These are individuals who are normally applying to ten, twelve medical schools across the country and potentially in North America. In this situation, we're able to do it [remote interviews via Zoom] where they are in their homes."

Sita Gourishankar, assistant dean of admissions for undergraduate medical education, University of Alberta

"This large of an increase is unprecedented when considering that the number of applications has been rising by an average of 2.5 percent over the past twenty years."

"Some students may have been motivated by seeing heroic doctors on the front lines of the COVID-19 pandemic. Some aspects of the application process also became easier as some medical schools extended their deadlines."

"We survey incoming medical school students every year and will learn more next fall about why this year's applicants decided to apply."

Dr.Geoffrey York, senior director, student affairs and programs, Association of American Medical Colleges

"There were some challenges related to the online interview and I definitely interact much better, I would say, in person."

"For example, in reading body language, that sort of thing, so those were sort of unique challenges, but everyone was in the same boat."

"It interests me, I guess, being able to be in that field and help people out. During COVID when people are sitting in isolation, sometimes I feel kind of helpless or useless in the sense that I can't be out doing something."

Sarah Veber, prospective medical student, Newfoundland

Medical workers in protective clothing move the body of a deceased patient to a refrigerated holding centre. © 2020 Bloomberg Finance LP

The current situation that is stretching the patience, perseverance and knowledge of health-care professionals across the globe, leaving doctors and nurses exhausted in the never-ending call upon their professional expertise during the SARS-CoV-2 virus pandemic appears to have appealed to the idealist in young aspirants to the medical field, expressed in the fact that medical school admission applicants have been steadily rising of late. A hopeful sign, that the young and medical-service-inclined are prepared to replace the profession's older physicians on the verge of exhausted collapse.

Medical schools across North America are now experiencing a surge in applications for the 2021-22 academic year that is viewed as unprecedented in its overall response to the global pandemic. Both in Canada and in the United States, applications to medical schools have risen by about 18 percent  overall. Medical schools in Ontario are working around a 10.9 percent greater number of applications in comparison to last year, while nursing programs in the province have seen a large boost of 17.5 percent. No one really quite understands what the increased interest can be attributed to.

At Washington State University, the senior associate dean for admissions and student affairs, Dr.Leila Harrison states that despite no conclusive research behind the increase, indicators point toward the pandemic contributing to the rise by inspiring young people to want to do something worthwhile for their communities, giving them a sense of mission to aspire toward. "It's just the idea that potentially seeing Dr. [Anthony] Fauci [the U.S. government's top medical adviser], all the impact he's made in his expertise in this pandemic, that maybe has inspired hopeful doctors to say, 'You know what, I'm gonna go for it this cycle'."

Entry processes have undergone a change as well, linked to COVID-protective measures that have become universal in an effort to contain the spread of the coronavirus, with medical schools adapting to the new situation. Select students receive invitations to attend interviews -- remotely -- which result in some prospective students receiving letters of acceptance. Virtual interviews have their place in the process; a plus for distancing; a minus for communicating person-to-person other than virtually.

 

A doctor checks on a Covid-19-infected patient connected to a ventilator. Getty

Like every other facet of society, communications, and work, it seems likely to Ms.Gourishankar in her professional capacity, that virtual interviews will become normalized and acknowledged as a positive tool in the process of welcoming new medical students. It is an option offering greater flexibility in the interview process since it can be conducted from anywhere to anywhere. And that convenient option may act as a spur for more potential medical students to explore all avenues since travel is no longer involved.

 

And then there is the issue of physician burn-out. "I think there's a lot of doctors right now who are looking at different careers. To see your patients die and you know what's going to happen is a really hard thing for any health care workers to have to continue to put up with", explained family physician Dr.Kate Bisby, who worries that ultimately communities across Canada may be affected, with fewer primary care doctors, as more opt to retire early, exhausted from overwork. 

 

Doctor Burnout   Getty

In September, a study was released in the United States by the Primary Care Collaborative which showed that 19 percent of physicians they surveyed believed a doctor in their clinic had, or was planning to retire early as a direct result of how the COVID-19 pandemic impacted on them. Another study released in February indicated that though burnout was increasing among family doctors, none those the study surveyed planned to retire early, as a result of exhaustion.

 

A study published by the Cambridge University Press Public Health Emergency Collection discovered that a large number of emergency medicine physicians in Canada had one symptom at least of burnout before the advent of COVID, while a separate study looking at past health emergencies found burnout among doctors is bound to increase during a pandemic. While 81 percent of physicians reported high emotional well-being through findings by a 2018 Canadian Medical Association report, 26 percent reported "high emotional exhaustion" and thirty-four percent of respondents screened positive for depression.

"We are very concerned about the impact this pandemic is having on our health workforce -- an impact  that will be felt for years to come."

"It is therefore important that we have serious conversations about our health-care system, so that we improve access to care while ensuring the well being of those who deliver care to Canadians."

Dr.Ann Collins, president, Canadian Medical Association

"It's been pretty crazy in the sense that it's both really difficult, but it's also kind of a very rare and interesting unique fortunate learning opportunity for us. It's tough, because obviously, it's a pandemic, and it's difficult for everybody, especially health-care providers."

"We all presumably went into medicine in the first place [to] make a difference and make a positive impact in our communities, and, you know, advocate for vulnerable people who weren't always able to advocate for themselves."

"And so I'm still super excited to be able to do that. And the pandemic really doesn't change anything about that."

Nick Taylor, second-year medical student, University of Alberta