Vaccine Hesitancy

Should I get the COVID-19 vaccine?

This might be a burning question in your mind today. With news of the COVID-19 virus having some unsavory side effects, one cannot but feel anxious whether to have it. After all, we have just been recently paralyzed with a vaccine scare for Dengue Fever that affected our belief in the vaccination program, in general.

Added to this dilemma is where the vaccine can be procured. We want to live out our lives as before, with social interactions unhindered. But fears surrounding the vaccine are circulating, and it is difficult to make a decision whether to have the vaccine or not.

In some countries, vaccination is in full swing. Some are being prioritized, such as the frontline medical personnel who are deemed most vulnerable. Though initially unsure of the consequences, they readily accepted the challenge of being the first recipients of the FDA-approved shots. In India, however, it was reported that some vaccines go to waste because people do not show up as scheduled. To address this, even unscheduled participants are now being accommodated for immunization. “Each vial has 10 doses, and if only five people are coming, either we have to deny vaccination for these five people or waste five doses,” said Tamil Nadu’s director of public health and preventive medicine Dr. T.S. Selvavinayagam.

Let us try to look into the issues and see whether they are based on facts.

First, the adverse effects being reported so far are not alarming. News on some deaths were found to be due to an underlying medical illness, not brought about by the vaccine. Most of the adverse effects are due to injection site reactions, which are expected, and which usually go away in a few days. The adverse effects of COVID-19 vaccine are mainly local ones including pain, itching, and redness (1).

Now comes the benefits. According to studies, the available vaccines have an efficacy that hovers around 90 percent or even better. Another vaccine candidate has a lower efficacy rate, but it is preferred by certain government sectors.  Could science shed more light on this discrepancy to make us have better decisions? Definitely.

Source: https://www.statista.com/chart/23510/estimated-effectiveness-of-covid-19-vaccine-candidates/

The hesitation comes from our inability to remove the noise and find what is relevant. Science will do this. It will remove the extraneous variables and focus on the truth. When decisions are based on scientific knowledge and not hearsay, you can be sure that whatever the outcome is, it will be consistent. Consistency produces results. Ask any athlete or marketing professional, and they will tell you how consistency produces the outcomes they desire.

Just believe in science. Shun the fears and unfounded factoids away. Remove the hesitation with evidence.

SOURCE:

Yuan, P., Ai, P., Liu, Y., Ai, Z., Wang, Y., Cao, W., Xia, X., & Zheng, J. C. (2020). Safety, Tolerability, and Immunogenicity of COVID-19 Vaccines: A Systematic Review and Meta-Analysis. medRxiv : the preprint server for health sciences, 2020.11.03.20224998. https://doi.org/10.1101/2020.11.03.20224998

By-Product

Everything is now online. Marketing businesses have gone to this route especially during the pandemic. It is said that most businesses today can no longer survive without an online presence.

This also included artists. We have seen most of them being more active in social media these days. Particularly for those from a major television station that just closed its doors.

Why is this so? When you are selling something, there is always a by-product of what is peddled. And this by-product can be extended to include more potential clients, more satisfied individuals, and more sales. This is called influence. And physical presence is not needed for this.

As a physician, there is a mindset that the only product that one has is the ability to heal. It may be the physician’s most lucrative business. But that is no longer true today. A doctor can create online teaching materials. Just look at Dr. Willie Ong, who earns more through his YouTube channel. Or a physician can write a book on his or her experiences. It does not have to be limited to non-fiction, but one can venture into fiction as well.

This is what we now have with the advent of technology, and even with a pandemic, one’s influence remains because our world has now become interconnected.

But with this comes greater responsibility. To ensure that only the truth comes out. To acknowledge your source of information. To make sure that your message reaches the right people. Companies and individuals must be conscious of this.
The best by-product of being a physician is influence. Just as marketing professionals try to exert influence to sell a product or service, it is actually a doctor’s influence that spurs patients to action. The mere act of going to a doctor for a medical consultation is a chore, even if it is done online. What would happen if a doctor does not recognize this reality and nonchalantly tries to rattle off one question after another without empathy? Can you make a person comfortable during a physical exam? Can a doctor truly make a patient feel her compassion even if the encounter is done virtually? How is this influence utilized to improve treatment outcomes?

This aspect of healing becomes even more important at the end of life. How can you give hope to the hopeless? How can you create an environment of joviality in misery? No amount of training can actually create this ability. It is simply inherent in a physician’s DNA. It is there. It simply has to be expressed, like a promoter unwinding the cell’s gene to unlock its potential.

We have heard of the placebo effect and its negative connotation. It is time to use the placebo effect for a positive outcome. In this day and age, when technology has started to take over most of human function, there is something that gadgets and equipment can never replace. It is the healing power of the human touch. Healing is the by-product of the physician’s heart.

Cytokine Storm

Jennifer R. Tisoncik et al. Microbiiol. Mol. Biol. Rev.2012; doi 10.1128/MMBR.05015-11

During this COVID-19 pandemic, a lot has been mentioned in popular media about a cytokine storm. It is said that most mortalities due to COVID-19 are attributed to this biological phenomenon, where the body’s immune response is overwhelmed by an infectious agent. Though mounting an immune response is the body’s normal reaction when bacteria or viruses enter the system, too much reactivity may result in organ damage and eventually death. Thus, one of the therapeutic measures undertaken to combat the cytokine storm is to slow down its progression.

The first use of the term “cytokine storm” appears to be in an article published in 1993 on graft-versus-host disease after a transplant operation. Its subsequent use in infectious disease began in early 2000, most especially when SARS-CoV 1 became a pandemic. Normally, when the human body encounters a germ, the immune system attacks the invader and tries to neutralize it. Sometimes, the army of defenders behave out of control, transforming in a “stormy” aftermath. Variants of this hyperactive immune reaction occur in an array of conditions, triggered by infection, faulty genes, or autoimmune disorders (where the body thinks its own tissues are enemies).   

The term "cytokine" is derived from a combination of two Greek words - "cyto" meaning cell and "kinos" meaning movement.  Cytokines are cell signaling molecules that aid cell-to-cell communication in immune responses and stimulate the movement of cells towards sites of inflammation, infection and trauma.  Most are produced by T-helper lymphocytes, but other cells can also produce them.

During an innate immune response to a viral infection, pattern recognition receptors (PRRs) recognize different molecular structures that are characteristic to the invading virus. These molecular structures are referred to as pathogen associated molecular patterns (PAMPs).  The binding of PAMPs to PRRs triggers an inflammatory response against the invading virus resulting in the activation of several signaling pathways that trigger gene expression. Once the gene is expressed, cytokines are generated.  

When the cytokines that raise immune activity become too abundant, the immune system may not be able to apply the brakes. Immune cells spread beyond infected body parts and start attacking healthy organs, destroying red and white blood cells, and damaging the liver. Blood vessel walls open up to let immune cells into surrounding tissues, but the vessels get porous. The lungs start to swell with fluid, and blood pressure drops. Blood clots may form throughout the body, further compromising the circulation. This is the reason why we hear a lot of those who perish from COVID-19 report signs such as bleeding, pallor, lowered blood pressure, and of course, breathlessness.  Most patients experiencing a storm will have a fever, and about half will have some sort of nervous system symptoms, such as headache, seizures or even coma.

The solution to a storm is to quiet the destructive immune response. Steroids are often the first choice of treatment, so a lot of these drugs are given. There are also medications that interfere with specific cytokines, and because of their specificity, they may produce less side effects. None of these are guaranteed cures. Factors such as genetics and other medical conditions such as Diabetes Mellitus and heart disease can complicate matters. The biggest trick in a cytokine storm is to recognize it, and treat it early. However, you have to balance the benefits of a drug with the risks. Thus, these treatments are only given in advanced disease states.

SOURCES:

Tisoncik JR, Korth MJ, Simmons CP, Farrar J, Martin TR, Katze MG. Into the eye of the cytokine storm. Microbiol Mol Biol Rev. 2012;76(1):16-32.

Sherwani S, Khan MWA. Cytokine Response in SARS-CoV-2 Infection in the Elderly. J Inflamm Res. 2020;13:737-747.

Zhang W, Zhao Y, Zhang F, et al. The use of anti-inflammatory drugs in the treatment of people with severe coronavirus disease 2019 (COVID-19): The Perspectives of clinical immunologists from China. Clin Immunol. 2020;214:108393.

Bucket List

Recently, I published my first book on Amazon Kindle. “Unrequited” is a story of life’s ups and downs, told in poetry form. As poetry seems to be a “lost literary form” in this day and age, the Shakespeare in me was jolted into completing it during this time, as I was always home.

During my interview with Mr. Anton Diaz, I was asked about my inspiration in writing the book. It is a conglomerate of various experiences, which may not necessarily be mine. Being an observer of life’s struggles and triumphs enables me to put myself in another persona – what would I do when I am in someone’s shoes? Perhaps my training as a family physician and my exposure to hospice patients helped me develop this skill.

But more than any skill, the key to writing a book is not inspiration or desire – but a determination to finish it. Setting an exact date to finish is key, and scheduling time to write is important. Word by word, page by page, the story comes to life – never mind the grammar, initially.  There is a tendency towards perfectionism, but this desire must be rejected, for no book is too perfect (except the bible, and even this is subject to debate).

What is in your bucket list?

Is it written on any piece of paper, or in an electronic file? If not, write it down. Lists or anything in print, which can be seen, has a way of spurring people into action. It also helps us remember. This is why I also love the Notes App on my smartphone. When a sudden thought comes to me and I do not have a pen, I can simply type away.

So what do you put on your list?

The movie Bucket List starring Jack Nicholson comes to mind. It may be an adventure. Or a project. An unfulfilled wish. It may not matter if it is truly attainable – this list is for inspiration. If it becomes reality – great! If not, the fact that it was written may have pushed you to go for it – and you learned through the process. You can revise the goal to something more realistic later.

What must we aim for when creating a bucket list?

Ultimately, we want to be remembered, but there must be something more to that. Extend the goal to something that does not just benefit you. It must benefit those around you. It may sound simple to you, but it may be a big deal for those whose lives you touch.

“Unrequited” is not just for me. It is for those who have struggled. It is for those who have won and lost. It is for those in the depths of despair. For those who have not been given a response. People who have gone through life and wonder what direction to take when things turn out for the worse. Its last part, “Love Is Hopeful”, brings out the goodness in all of us. For where there is hope, there is a way. And the truth is, The Way has always been there, since the beginning of time. And that is The Word.