Good Old Forum

I attended another web-based training, "Raise the Rate: Improving Provider and Patient COVID-19 Vaccine Confidence at the Medical Encounter" hosted by North Dakota Public Health Training Network (NDPHTN) through the approved Certified Public Health Continuing Education (CPHCE) credit listed at Train.org (https://www.train.org/main/course/1101918/).

Once again, I would like to share the official video and my notes for your information purpose. Please watch the video for details!


Covid vaccination rates:
As of January 13, 2022,

• 79.4% of the population 5 years old and above have completed SINGLE Covid vaccine dose
• 66.8% of the population 5 years old and above have completed PRIMARY Covid vaccine series
• 40.6% of the population 18 years old and above have completed BOOSTER Covid vaccine dose

Morbidity and mortality of Covid-19
Necessary (as is, young, already infected with Covid, etc) vs. exaggerated?

1. Before and After Vaccination - All-cause Mortality Deaths in U.S.

• There was  weekly 5000-40,000 excess all-cause mortality deaths in U.S., more than predicted from the trend during the pandemic of 2020 and 2021, also exceding what was during the 2017-2018 Flu Season
• Weekly deaths in U.S significantly decline with the initiation of the Covid vaccine
• 
• In general, more deaths caused by Covid in U.S than COMBINED deaths from WW1, WW2, Korea, Vietnam, and 9/11 (could have been prvented with Covid vaccination)

2. "I'm healthy"
Understanding Infection Fatility Ratio (IFR) and Case Fatality Ratio (CFR)

• IFR = # of Deaths / Number of Infections x100 (includes all symptomatic and asymptomatic infections, mainly from uses  of serologic studies)
• CFR = # of Deaths / Number of Cases x100 (includes all persons with clinical symptoms, mainly confirmed by lab testing)
• RATE and RATIO are not the same, COMMON MISTAKE by the public, RATE =/= RATIO, RATE = different units top/bottom on the division numerator/denominator, RATIO = same units top/bottom on the division numerator/denominator
• When someone says "I'm healthy" aka "no symptoms / asymptomatic", it's referencing to Infection Fatality Ratio (IFR) that includes asymptomatic, NOT Case Fatality Ratio (CFR) that includes symptomatic
  
  • Actual overall Case-Fatality Ratio (CFR) in U.S = 1.6% (is HIGH), meaning 1.6% of individuals who seek care and are infected with Covid will die
  • Infection Fatality Ratio in U.S = 0.1% (0.01-0.67% range)
  • In general, Covid vaccinations have decreased deaths.

3. Complications for survivors of Covid infection
"Already infected with Covid and survived, and in that 97-99% survivor group"

• A 2021 study shows risk of death in 10 months after hospitalization for Covid management by Covid protocol (2020) was HIGHER than seen during Influenza pandemic (2017/2018)
• So, even after surviving hospitalization with Covid, death after that is 63-73% greater than death after hospitalization for influenza in 2017/2018 season
• 1-year outcomes in Covid-19 hospital survivors: any symptoms, fatigue or weakness (greater in women), sleep problems, smell disorder (anosmia), taste disorder (ageusia), anxiety or depression (greater in women), persistent CT CHEST abnormality, abnormal gas exchange in the lung - gas effusion (greater in women), ongoing shortness of breath - SOB / dyspnea
• 
• United Kingdom U.K Biobank Study showed taste, smell, emotion, memory processing and memory storage areas of the brain shrinking statistically significantly after Covid infection (supported by neuropsychiatric testing after Covid-19 recovery by Becker JH, JAMA Open Network, October 2021)
• Covid-19 infection increases diabetes risk (1.3-2.7 X increased risk or 57% increased risk in CHILDREN - MMWR and JAMA Pediatrics January 2022; 70% increased risk in 4 weeks to 1 year after infection in ADULTS - Rezel-Potts E, medRxivDec 2021, 40% increased risk at 1 year and 3 X increased risk if hospitalized in ADULTS - Al-Aly Z, Lancet Diabetes Endocrinology March 2022)
• Covid vaccines do decrease severe deaths and infection rates, along with requirements for hospitalization from Covid.
• Covid vaccines may also decrease "LONG Covid", Covid symptoms after hospitalization or recovery

4. Attributes and impact of the delta and omicron variants

Delta Covid Variant

Quote"The delta variant is more efficient at transmission due to genetic changes that allow it to produce large number of infectious particles" - W.H.O

• >1000x higher viral load than earlier strains, 2-3 X more contagious than original strain, 2 X more likely to be hospitalized (surprisingly > 65 years old has flattened rate of death/hospitalization, likely because of higher vaccination rate in that popular after the original strain)

Omicron Covid Variant

• Much more transmissible than delta
• Omicron mutations lead to decreased viral antibody neutralization for previously infected or vaccinated individuals (2 dose Pfizer & Moderna vaccines provide 70% against omicron hospitalization and 10-33% against omicron infection)
• Highest hospitalization in <5 and > 60
• BUT, LESS SEVERE disease caused than delta
• Covid booster protects infection in 76% and protects severe disease in 85-90%

Stealth Omicron Covid Variant (Omicron BA.2 Stealth variant - version 2)

• Similar symptoms to the original omicron variant
• Prior omicron BA.1 infection provides protection against BA.2 omicron Stealth variant infection
• Similar coverage by current vaccines
• Causing 50% of infection in Denmark and dominant in India
• ID-ed in U.S.

Deltacron

• ID-ed in Cyprus
• Mixed of delta and omicron genetic characters

5. Take the vaccine or take the virus?

Quote"If you haven't had the Covid vaccine or Covid-19 infection yet, very likely you will [be exposed and infected] in the next few months"

6. Understand current evidence for Covid vaccine efficacy

• Reasons for declining vaccine efficacy in general: age, time from vaccination (vaccine durability), variant coverage
• BUT - GOOD THING - even with the declined vaccination effectiveness, STILL 55-65% less likely to get infection (vs. unvaccinated), BOOSTER vaccine dose IS BENEFICIAL
• Example when delta variant became the most common variant, fully vaccinated individuals had 5 X reduced risk of infection, > 10 X reduced risk of hospitalization, > 10 X reduced risk of death from Covid
• Janssen, Pfizer, or Moderna vaccine 6-months study back April-September 2021: 6.1 X greater risk of testing positive for Covid-19 and 11.3 X greater risk of dying from Covid-19 if UNVACCINATED
• Sanford health October 2021 study: 91-97% of hospitalized, in ICU, on ventilators are UNVACCINATED
• MMWR study for 11 million unvaccinated vs vaccinated (disclaimer: bias in the studies based on the baseline health status of a person): mRNA Covid vaccine decreased Covid death by 66-69%
  
• 2021 Study of 700,000 veterans' survival over 26 weeks post Covid PCR test
  
• NEJM Israel study: marked reduction in reinfection if received at least 1 dose of vaccine in people with history of Covid infection (Natural alone is not efficient, but Natural immunity + 1 Dose has some benefits, if not optimal)

7. Base Rate Fallacy

Quote"delta variant is infecting vaccinated people, representing as many as 50% of new cases" - Report from Israel from June 26 2021

• Israel was with the highest vaccination rate.
• So why is this the case? Base Rate Fallacy.

Quote"The higher the vaccinated rate of a population, the higher the number of infected individuals will be vaccinated, even if they have a ~5-fold decrease in infection rate due to vaccinated status vs. the unvaccinated"

8. Booster and third dose recommendations (Covid vaccine third dose is not necessarily a booster dose)

• Haider G, et al. MedRxiv. 2021 study: only 37% with solid organ transplant has neutralizing antibody from the vaccine, in 55% with hematologic malignancy, in 82% with solid tumors, in 84% with autoimmune diseases, in 95% with HIV, in 98% who are healthy healthcare workers
• "In moderately or severely immune-compromised patients, a third dose is recommended as soon as 28 days after the second dose. This is NOT A BOOSTER DOSE but a THIRD DOSE OF A PRIMARY SERIES."
• Pfizer and Moderna vaccines: Covid vaccine booster 5 months after completion of the primary series
• J&J vaccine: Covid vaccine booster 2 months after the first dose
• can "mix and match" booster doses after completion of the primary vaccination regimen as appropriate for their age, unless there is a preference or complication
• Which age group can receive what vaccine? 12 years and older = Pfizer, 18 years and older = Moderna and J&J Covid vaccines
• Boosters dramatically increased neutralizing antibodies against symptomatic infections of omicron, may provide 76% protection against infection and 85%-90% protection against severe disease
• Increased Covid-19 booster rate in the populations will blunt the outbreak of omicron and other Covid variants currently circulating

9. Covid Vaccine Safety Datalink program as part of the US vaccine safety system
Covid vaccine safety and adverse reactions

Quote"Covid vaccines are some of the most studied and monitored vaccines in the world's history!"

QuoteBillions of doses have been administered since late 2020, so LOTS OF STUDY DATA from WORLDWIDE EXTENSIVE EXPERIENCE to study efficacy and safety!

U.S has multi-layer system for safety monitoring:

• Phase I-III Clinical Trials
• Vaccine Adverse Events Reporting System (VAERS)
• Clinical Immunization Safety Assessment (CISA) Project
• Vaccine Safety Datalink (VSD) for rapid cycle assessments for COVID19 vaccines: developed by CDC 30 years ago, covers 12 million people linked through Managed Care Organizations (MCOs), includes vaccinations/hospital and outpatient info/lab data, utilizes Rapid Cycle Analysis (RCA) - REAL TIME WEEKLY comparing rates of pre-specified outcomes in pre-specified time windows
• Post-licensure Rapid Immunization Safety Monitoring System (PRISM)
• V-Safe

10. Absolute Excess Risks of acute kidney injury, appendicitis, arrhythmia, deep vein thrombosis (DVT), herpese zoster infection, intracranial hemorrhage, lymphadenopathy, myocardial infection (MI),  myocarditis, pericarditis, and pulmonary embolism (PE) after Covid Vaccination vs. Covid SARS-CoV-2 Infection:

• 
• COVID INFECTION is with a GREATER HEALTH RISK (orange bars)!
• The Covid vaccine is not associated with the higher risk, although there is a risk (blue bars)!

Rare serious adverse events after COVID19 vaccination:

• All vaccines: anaphylaxis, needing 15-30 min waiting period after vaccination at the vaccination center, 5/million or 0.0005%
• Janssen vaccine: TTS (thrombosis with thrombocytopenia syndrome) 3/1000000 or 0.0003% risk, GBS (Guillain-Barre syndrome) 7/million or 0.0007%
• mRNA vaccines (preferred for all age and gender groups due to lower risk of and fewer adverse effects): myocarditis 3.5/million or 0.00035%

Covid vaccine DOES NOT CAUSE female infertility

mRNA Covid vaccines are non-replicating and do not change the DNA of the vaccine recipients

11. Approaches to vaccine conversations during the medical encounter:

• Building TRUST
• Influencing on attitudes regarding potential Covid vaccination
• Discussing about intent for vaccination, knowledge on the importance of Covid19 and Covid vaccine, and underlying worries about Covid-19 vaccine side effects
• Spending more time to attend to questions, concerns, and comments on the Covid vaccine and safety
• Listening to, understanding, and being the source of solution for the patient
• Avoiding participatory recommendation leaving uncertainty, like "WOULD YOU like [XYZ] vaccine today?"
• Using presumptive recommendation emphasizing the vaccine's essential, like "I STRONGLY RECOMMEND we give you the vaccine today to protect you against [ABC or severe disease and death]. Do you have any questions or concerns?"
• Sharing relatable stories
• Motivational interviewing
• E.A.S.E: ELICIT main concerns, ACKNOWLEDGE main concerns, SHARE commitment, EDUCATE & ENDORSE with consent and understandable language level

Shared by Kaung M. Ko, MD, MPH, CPH