Medical Discussion of Coronavirus

[Hatton]

The strength of a natural immune response and the rate at which it fades is highly variable. I would be fine with recognizing natural immunity as an alternative to vaccination provided that there is firm medical documentation of the date of Covid infection (none of this “I know I had Covid!“ crap) and that immunization is required six months after the infection (unless the person has been unfortunate enough to have a second documented Covid infection during that time).

Eventually we will figure out what level of antibody titer correlates with good protection, and we will be able to set titer levels as a screen for both vaccinated and unvaccinated people. We may get a good test of T cell response to Covid as well, which would also be extremely helpful.

This makes so much sense. I think the non-medical public forgets that this is a totally new disease and medicine is working on this like the "Manhattan Project" but we need time to formalize reference ranges for antibody titers for example. Eventually data will exist to determine when to boost people and which vaccine to use.

[Tim]

This makes so much sense. I think the non-medical public forgets that this is a totally new disease and medicine is working on this like the "Manhattan Project" but we need time to formalize reference ranges for antibody titers for example. Eventually data will exist to determine when to boost people and which vaccine to use.

Yes it makes sense. To John Q Public, there is no debating that the “Manhattan Project” is finished. Warp Speed was a success. Done, finished, over. Vaccines (tremendously effective) and treatments are available.
No additional trillion dollars needed. When you say “we”, it is so nebulous. Who is “we”? No government officials or scientists seem to be a budget issue currently relating to needed refinements. Stay at home mandates, mask mandates, vaccine mandates are all front and center, BUT not one word other than “trust me”, “get vaccinated”.
I wish “we” would layout a plan for actual additional work and the cost benefits could be debated. From John Q Public’s point of view, there is zero additional goals. Medicine might understand it better, but what are the deliverables?
This project must be top secret. John Q Public and the government certainly are in the dark. Does not seem to have a top priority.

Quite honestly, even the desire for amusement and travel of those on this forum and in power, the emergency seems over. Business as usual.

That seems to be John Q Public’s opinion. Job well done. Not much more to see. Off to vacation.

No one expects understanding and improvements to cease. “Someone” is working on it, just as usual.

Hatton, I completely agree with how logical this is. Things will improve gradually, not at rate of Warp Speed or the Manhattan Project.

[Kamban]

And people like Colin Powell are the reason why. I wonder how our young, banned med student would feel about people talking about COVID infection as if it was no big deal if HE had a hematologist malignancy?

I thought that Mr. Powell had multiple myeloma but am unsure if he was in remission from a transplant or he was actively being treated with immunotherapy. Maybe that was the reason he could not mount a full sustained response to even a complete course of COVID vaccinations.

[Kamban]

Eventually we will figure out what level of antibody titer correlates with good protection, and we will be able to set titer levels as a screen for both vaccinated and unvaccinated people. We may get a good test of T cell response to Covid as well, which would also be extremely helpful.

I was hoping we would have that by now so that we can categorize people as immune vs non-immune rather than vaccinated vs non-vaccinated.

[Shant]

Part of the problem as I understand it is that it attacks so many body tissues and preliminary studies I've read indicate that people with a mostly GI course of the disease for instance are not developing as long-lasting of an immune response. That makes it tough to sort out a global rule for natural immunity.

[FIREshrink]

I was hoping we would have that by now so that we can categorize people as immune vs non-immune rather than vaccinated vs non-vaccinated.

Doesn't cellular response matter more especially for serious disease/hospitalization/ventilation/death?

[FIREshrink]

That is the difference between a pandemic/epidemic and an endemic disease. In a pandemic or epidemic the pathogen is so prevalent that there is really no way that immunocompromised people can protect themselves solely through their own actions. The entire community needs to respond in order to lower the circulating level of the pathogen. With an endemic disease, the circulating pathogen is never present at high levels.

I read that fully vaccinated 80 year olds have the same risks of serious disease as unvaccinated 50-64 year olds. If that's true, that's awfully sobering. Think about how many unvaccinated 50-64 year olds have died of Covid in the last 18 months.

[artemis]

Doesn't cellular response matter more especially for serious disease/hospitalization/ventilation/death?

Yes, but it appears to be the systemic IgM and IgG responses which stops the disease from becoming symptomatic in the first place. Which would explain Shant's comment that folks who had primarily GI symptoms have a shorter period of natural immunity: I bet they have great gut-localized IgA immunity, it's their systemic IgG immunity which is lacking. Ditto the observation that people who were vaccinated vey early in the pandemic may have a symptomatic breakthrough infection, but are less likely to be hospitalized than unvaccinated folks; their levels of circulating anti-spike-protein IgG may have fallen low enough that COVID can gain an initial foothold, but their T-cell immune response remains intact so the disease doesn't become too severe before their memory B-cells proliferate and mature into plasma cells, causing their IgG levels rebound and finish it off.

[artemis]

I read that fully vaccinated 80 year olds have the same risks of serious disease as unvaccinated 50-64 year olds. If that's true, that's awfully sobering. Think about how many unvaccinated 50-64 year olds have died of Covid in the last 18 months.

It's very sobering, and a good reason why we want to drive the circulating levels of this virus down ASAP. I think a lot of lay people either don't know or forget that not all comorbidities are avoidable. There's no fixing advanced age, immunosuppression caused by chronic medical conditions, or just plain inheriting the wrong HLA genes. Those folks simply won't be reasonably safe as long as Covid is in the pandemic/epidemic phase.

[StarTrekDoc]

Great discussion - and all still unknown cause all of our hands are on deck trying to deal with this and unable to really put together nice studies that take a bit of manpower to setup, deploy and data crunch.

-Should we have reference ranges for some general immunity status? perhaps--if this thing doesn't keep mutating and reset the target range. (eg Alpha vs Delta)

-Is there a cell mediated component - most likely. Just harder to measure that in general.

-Natural superior to Immunized? -- Maybe. Counterpoint -- one has to survive natural infection. Idaho and Montana citizens affected by this and rationing care and healthcare workers should give testimonials on this on the talk circuits. Even the natural + vaccinated shows benefit over natural alone. So paying the price of society burden for natural outperforming vaccinated makes little sense at the society level.

Yes, the pendulum has swung significantly toward the 'what have you done for me lately' side of things. That's why the only real counter left is 'show me the money (vaccination)' where the threat of dismissal on critical sector jobs forces choosing ones paycheck.

[pulmdoc]

This is more of a philosophical/ethical argument, but at-risk patients have always been out there and generally the responsibility for protecting them has been mainly on the patients themselves. We all have patients that have severe disease sufficient that even a minor URI can be lethal. We haven't built health policy around protecting them, and we probably shouldn't. We tell them and their relatives to be careful about exposure to illness, and in the case of COVID, to get vaccinated.

I understand the argument that COVID is so prevalent and unique that everybody has to pitch in to control it, but building health policy around protecting a small subset of the population isn't practical for very long.

If ONLY the highest risk patients could get lifethreatening illness, then putting the onus of protection on them makes sense (This was thesis of Barrington declaration and has been recommended for transplant recipients for decades). Sadly, the baseline rate of lifethreatening illness in "low risk" individuals is still quite high so that argument falls apart. This Delta wave has been almost entirely made up of 20-50 year old unvaccinated folks who didn't regularly doctor, didn't think they could get deadly sick, and were wrong.

[Tim]

"This Delta wave has been almost entirely made up of 20-50 year old unvaccinated folks who didn't regularly doctor,didn't think they could get deadly sick, and were wrong."

This thinking did not appear out of thin air, is was a learned response. All the work that went into the allocations was widely publicized. The public bought into the Phases and all of the good for society. December 20, 2020.

https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2020-12/slides-12-20/02-COVID-Dooling-508.pdf

The whole country was educated about the phases and risk profiles. This is what they were taught about vaccinations. 16-64 were low risk and were not a priority.
Yes, things have changed and now it appears they are a number 1 priority. Less than one year later. Most of this occurred in the summer when school was out. Not only for students, but for the 20-50 year old unvaccinated folks. Blame the students or blame the new teachers? Makes no difference. The allocations ceased to be an issue in late spring and turning the priorities around were unsuccessful. They didn't learn that there was a second summer session.The world changed.

I didn't see the study where "unvaccinated" didn't regularly doctor. I do think some of the demographics show many are in underserved populations.

[pitt1166]

OK so i haven't been paying too much attention to all this booster discussion. I am a physician and i received my 2 doses of the pfizer vaccine earlier this year...

i'm now due for a 3rd (booster) shot....

what's the consensus for which shot i should get? pfizer or moderna? i don't have a horse in this race, whatever is more protective.

[MaxPower]

OK so i haven't been paying too much attention to all this booster discussion. I am a physician and i received my 2 doses of the pfizer vaccine earlier this year...

i'm now due for a 3rd (booster) shot....

what's the consensus for which shot i should get? pfizer or moderna? i don't have a horse in this race, whatever is more protective.

I’m in your same position and am going to get Moderna. I want my immune system to have as much exposure as possible to different configurations of the spike protein, and since it already has a look at Pfizer’s version, why get the same one?

[Shant]

Locally data is showing Moderna has an advantage against the delta variant so that's what I'm planning to get. Although I'm disappointed there wasn't a delta-specific booster available before I needed a third dose.