Category: Fall 2020

According to polls, up to half of Americans will answer “no” to that question.  There are a variety of reasons for this.  Fear of the unknown is a common problem.  It is also impossible to make an informed decision about something that is not understood.  Maybe we can get a little bit of a handle on that here in a few words.  Let’s get to know this vaccine.

First of all, we are actually talking about more than one vaccine.  The first vaccine against COVID-19 to be approved by the FDA was the Pfizer vaccine.  Close on its heels, and likely to be approved any day now is the Moderna vaccine, which was discussed in the July MPDN article “Some good news about a promising COVID-19 vaccine.”

Pfizer and Moderna are both messenger RNA (mRNA) vaccines.  These vaccines use the machinery of the cell to manufacture proteins that the body can then recognize as foreign.  That is important, because this is how the immune system works (and using the immune system is how you fight off viruses). Under normal circumstances, if you are infected by a virus, for instance a cold virus, the virus will have proteins on its outer surface which are different from normal proteins in the human body.  Our immune system monitors the body for unusual proteins.  When these are found and recognized as foreign, the body targets and destroys the virus.  One way to imagine this might be to think of a hospital. The staff all wear a hospital ID. A person with the wrong ID would be recognized by security as someone who doesn’t belong. Hopefully, they won’t be destroyed, but you get the picture, right?

How do RNA vaccines work?

In the body every living cell contains DNA, the genetic code.  This genetic library contains all the information needed to make you, to repair injuries, to make proteins, and so on.  It works like this: DNA is a template.  Your cell can use small sections of your DNA to make mRNA.  That mRNA leaves the nucleus where the DNA is located to be used in machinery within the cell called a ribosome to make proteins. I know, it sounds complicated, but stick with me. Usually proteins serve some function in the body, for example building muscle cells. So, again, DNA makes mRNA, which makes proteins, which build things like muscles, or maybe tiny proteins on the surfaces of things.

Some very clever people have taken a look at the virus that causes COVID-19 and found that when we have an immune response to this virus we make a lot of antibodies against something called the spike protein.  The spike protein is the business end of the virus, and if it is targeted the virus will likely be destroyed. 

The Pfizer and Moderna vaccines contain mRNA that will be used by machinery of the cell to produce a molecule that looks like the spike protein. After doing this, the mRNA will degrade. To those that keep saying it will change your DNA, no, it will not do anything to your DNA-wrong direction!  Cells will then kick the new foreign protein made from mRNA out, and the immune system will see this foreign protein and develop antibodies against it.  The great thing about the immune system is that it tends to remember foreign invaders.  That is immunity. While we are not sure how long this memory will last for this particular invader, most of us believe vaccination will stop this pandemic if enough people take it. That is why we need you.

Some people are worried about potential side effects. Fair enough, but so far the data doesn’t show a lot of reason for concern. In studies some people experienced flulike symptoms following injection of the vaccine.  Flulike symptoms actually mean the immune system is working, not that the person was infected-as I have heard people guess. Those people couldn’t be infected by the vaccines, because no virus was injected. 

Amid the billions of people vaccinated over the next several months we might wind up having a relatively few people with serious side effects. If you give every person on Earth an aspirin the same thing will happen. That level of risk is not a good reason to skip the vaccine. Think of the odds in relation to you. The overall risk associated with receiving the vaccine has so far been very low (usually only minor symptoms among a minority of patients); whereas the risk of serious illness from COVID-19 is about 20%, and death from COVID-19 is somewhere around 2-3% for the general population (much higher for older and chronically ill individuals). Generally, your odds are much better with the vaccine than without. 

Finally, be careful where you get your information about this.  Talking heads, politicians, some commenters on Facebook, and other uninformed sources are not where you should be getting medical advice.  Defer to an expert.  Talk to your doctor, check with the Maine CDC (or listen to the updates). And, get in line for a vaccine. This is how we are going to defeat COVID-19.

As of yesterday, the date for which the latest data is available, there have been 11,801 confirmed and 1547 probable COVID-19 cases among Maine residents since testing for COVID-19 began.  This is a combined 13,348 cases, but does not include positive test results from out-of-state visitors or part time residents whose official residence is in another state.  The total also does not include those that were never tested and told to shelter in place unless symptoms became severe.   And yes, that still happens.  If a person has a known infection and a household contact becomes symptomatic, many are not being tested.  There are also those who are asymptomatic (maybe four-fold the number of symptomatic infections) who are typically not being tested unless part of a mass-testing operation at a congregate care facility, for example. 

The last time I reported on this on September 9, we had been seeing relatively low daily numbers: that day just 23 new cases. Generally, in August, September, and the majority of October, we would sometimes see over 50 new cases, but other times we would see a number in the teens, and the daily average was low.  Starting around the end of October we began to see higher case numbers: October 30: 103 cases, November 5: 183 cases, November 13: 244 cases.  In fact, we’ve broken 200 new cases a day regularly since mid-November.  Today there are 221 new cases. Thursday, December 3 we saw an all-time high of 346 new cases.  How did we go from 380 active cases of infection on September 9 to 3,041 today?  What changed?

It may be true that seasons had started to change and people were beginning to go indoors more toward the end of October.  I don’t think the effect was that great though, because the weather was actually pretty mild, and most days were nice.  I cannot stress enough that congregating with other people who are not part of your household is a bad idea, indoors or out. 

The virus is highly contagious, and as I have pointed out several times in MPDN, asymptomatic carriers can spread the virus and not even know it. 

You cannot tell by looking at someone that they are an asymptomatic carrier.  They cannot tell either.  Everyone should assume that they, and everyone around them can either catch or spread the virus that causes COVID-19. 

We should be standing at least six feet apart from people not in our household. We should be PROPERLY wearing and handling masks or facial coverings, wearing eye protection (yes, cover your eyes), washing hands, not touching our faces, and generally being COVID-aware.   Avoid indoor spaces with those outside of your household, and stand at least six feet apart, even if you are outdoors.    

Another issue with the rise in numbers is that people were getting together more in late October.  I don’t have data about this, but I kept hearing that friends would gather, or two different “bubbles” would meet up.  There were larger gatherings also.  One particularly egregious example was a “surprise” rally for Donald Trump at the Treworgy Family Orchard in Levant on Sunday, October 25.  According to NBC (1) “Supporters lined the streets along the route from Bangor, where he landed about half an hour earlier, to wave to the presidential motorcade… Hundreds of supporters greeted Trump at the orchard despite the event’s lack of publicity ahead of time.” 

According to the Independent (2) and other sources, the crowd grew to approximately 3,000 people.  Widely shared news coverage showed people crowded together, most not wearing masks, and voices raised.  Was this really a surprise?  That is a high number of people.  I suspect they did not all come from Bangor or Levant (Levant, which is just 10 miles from Bangor, has a population of about 2,900).  

I have made the point here before: louder voices generate more droplets, and project them farther too.  Droplets from infected people, even asymptomatic infected people, contain virus. If you are raising your own voice you have to breathe more deeply-and are more likely to inhale the droplets and virus in the air around you. 

This rally was an unbelievably reckless and unconscionable thing to do in the middle of a pandemic. I don’t think that rally alone was responsible for the massive increase in numbers, but it and other human contact has to be the answer.  And, it was the most obvious example of risky behavior in our state at the time. Speaking of time, look at the numbers: October 25, the day of the rally, the number of new cases in Maine was 64. Remember, it takes time for the virus to incubate, and for people to become ill and seek care. On November 5 the number was 183.  The rise in cases has been steady since, as have hospitalizations, and as have deaths due to COVID-19.  December 1 there were 20 deaths in one day, a record for Maine (3). The previous high number was 12 deaths on November 24.

Flash forward to Thanksgiving Day, November 26.  While apparently most people did not gather for the holiday this year, many did.  I think we all saw footage of busy airports on the news. I have had the unpleasant of circumstance of hearing about it from a minority of patients. Eating with others is a particularly effective way to give or receive an infection with COVID-19.  The CDC is clear about this when discussing food from restaurants, for example (4). The highest risk is when people eat together and seating is not spaced at least six feet apart.    Not to put too fine a point on it, but eating generates saliva.  Saliva generates droplets.  People tend to gather for Thanksgiving with loved ones, and you can’t eat with your mask on.  There is talking, laughing, etc.  If a virus is present it is likely to be spread. 

The problem is that we are beginning to stress hospitals in Maine, and if numbers continue to rise the way they are, we will exceed capacity in the coming weeks.  Think about what that means.  Put it into perspective.  During the first wave of COVID-19 in Maine our peak for hospitalizations was on May 26, when we had 34 patients in non-intensive care unit (ICU) hospital beds, and 26 in the ICU (5). For our purposes, consider the terms “ICU” and “critical care beds” interchangeable.  October 26, the day after the above rally in Levant, we had 8 non-ICU patients and 5 patients in ICU beds across the entire state.  We had sustained period of low hospitalization numbers since July.  That all began to change at the end of October, and by December 4 there were 119 patients hospitalized in non-ICU beds, and 45 in ICU beds in Maine. Today the Maine CDC reports 171 hospitalizations and 50 in an ICU. 

According to Dr. David Seder, intensivist at Maine Medical Center, about 30% of those who end up in an ICU bed at MMC will die.  As of today, 227 people have so far died from COVID-19 in Maine, about 2% of confirmed cases.  

The capacity of hospital critical care beds in Maine is 385.  At any given time there are many other critically ill patients in ICUs for a variety of reasons such as stroke, heart attack, injury, and so on.  Currently, 282 critical care beds are in use (6). Imagine when those beds are full.  If the hospital is at or past capacity your COVID-19 infection might not be treated, or at best will not be treated the way it would ideally, and neither will your stroke, your post-surgical complication, or any other illness.  In a system over-burdened, problems start to happen. And some of those problems include difficulty safely containing the virus in the hospital itself.

And, what if infection spreads through the hospital staff?  Face it, the more COVID-19 patients we see, the higher the risk of infection.  As of Friday, December 4, the Maine CDC reported 1,722 healthcare workers in Maine had been diagnosed with COVID-19 since testing began. These are confirmed cases.

What should we do with this information?  Simple, stay home.  Don’t congregate.  Don’t gather over the holidays.  Don’t go to a New Year’s Eve celebration.   Do all that you can to avoid catching or spreading COVID-19.  If you have relatives who are treating this like it doesn’t matter, talk to them. It does matter.  They might not get sick, the truth is, most infections result in only a mild illness.  But, 2% of people die. That is a lot of people, and if someone spreads COVID-19 they will have had a hand in those deaths. If they believe the absurd idea that we should all just catch COVID-19 and develop natural herd immunity, that is also a flawed premise. Maine has a population of about 1.3 million.  If 2% died, the number of deaths would be 26,000 people. But make no mistake, in a nightmare scenario like that the numbers would be much higher because the hospitals would be overwhelmed.

Do the right thing.

REFERENCES

1. https://www.nbcboston.com/news/politics/trump-scheduled-for-surprise-visit-to-maine-sunday-after-nh-rally/2217738/
2. . https://www.independent.co.uk/voices/the-maine-district-trump-has-become-obsessed-with-b1562898.html
3. https://www.pressherald.com/2020/12/01/twenty-deaths-reported-as-covid-19-storms-across-maine/
4.  https://www.cdc.gov/coronavirus/2019-ncov/community/organizations/business-employers/bars-restaurants.html
5. https://www.pressherald.com/2020/12/01/twenty-deaths-reported-as-covid-19-storms-across-maine/