Conquering COVID Part 2.5 (aka the 16th Installment in a Finite Series):
“Mild Instead of Severe or Catastrophic…I Want That Anytime?!”
(aka the Commercial We Should be Seeing on TV)
December 23, 2020
by Mark A. Moyad, MD, MPH
“I am concerned, of course, but I am also incredibly optimistic.”
(Note: All references are at the end of the column-thank you.)
It was just a month ago I was actually begging for touchdowns (my last column), and thank the person above, well we got several touchdowns with what appears to be multiple successful 2-point conversions! Sorry, but whenever I cannot adequately express my joy I resort to football or athletic analogies. Anyway, amazing so far! Yeah! Multiple vaccines are reporting preliminary data with 94-95% efficacy! Remember when 50% efficacy was going to be good enough for potential approval?! What is even more incredible, and deserves more attention, are the almost zero numbers of people so far experiencing severe COVID-19 disease that have received the real vaccine in clinical trials compared to the placebo product. Almost 100% of those in the vaccine group are NOT experiencing severe disease as of now, well that deserves a big WOW! Remember, a vaccine study has many endpoints or criteria that helps to determine a good vaccine from a great vaccine. For example, how long will it be effective after receiving it? Or can it prevent viral transmission from person-to-person? These are questions that still need to be answered. Still, if you can produce a vaccine with good safety, and not only prevent infections or prevent them from becoming symptomatic, then that is also a great thing. Again, even more, what you really want in a vaccine for horrible diseases is the ability to discourage a mild case from becoming a serious or severe case, prevent hospitalization and death. Preliminary results from these vaccines are that they can prevent something mild from becoming severe. This is a preliminary observation, and we need long-term data, but I am OPTIMISTIC, and of course you have known this about me for some time.
Imagine in this life if anything that could be severe or deadly could instead be reduced to mild or “no big deal”? Just imagine that for a moment. For example, imagine if you could prevent a car accident from becoming severe or potentially fatal, and instead turn that moment into a simple “fender bender” or just a basic flat tire? This would be a big deal! Imagine if you could stop a non-aggressive cancer from becoming an aggressive cancer. That would also be a big deal, right? Imagine if you could take a potentially fatal heart attack and turn it into a mild heart attack, then that would be a big deal. Imagine if you could lose only a small amount of money in any financial investment instead of a massive amount. Imagine if… okay… I think I have given you enough “imagine if” examples. You get my point here? Yes! In most situations in life, people would love to go back in time and turn a potential disaster into a mild event. I would love to go back in time and stop the Titanic from sinking and instead turn it into minor iceberg boat damage and an easily reparable situation, or even a rescue mission where everyone survives. I would love to take a potentially catastrophic plane crash and turn it into a scenario where everyone walks away with some minor injuries. This kind of thinking is simply not applied enough when it comes to vaccines for prevention and perhaps that is part of THE PROBLEM. What? Yes, perhaps the problem is that we think of vaccines as preventing a disease as if it is an ALL OR NOTHING EVENT, which is not the case in many situations. Preventing disease does not just suggest preventing the disease from ever happening, but it also suggests that when you get the disease, then preventing it from progressing or becoming life threatening is also CRITICAL.
Arguably, the greatest unsung positive area of general preventive vaccines is their ability to PREVENT SOMETHING MILD FROM BECOMING SEVERE. For example, the ability of the shingles vaccine known as “Shingrix” to prevent or reduce the severity of the debilitating chronic nerve pain issue called “post-herpetic neuralgia” (or PHN) is remarkable! Some people can suffer from this consequence for years and years and many cancer patients are at a higher risk of getting shingles if they have had chickenpox. PHN is a terrible complication associated with shingles. Ask someone that has it, or had it, and you will never forget their story. The shingles vaccine also has the ability to prevent eye damage or vision loss by reducing the risk of this virus from going into delicate places simply by preventing the condition completely. Herpes Zoster Ophthalmicus (HZO) or shingles of the eye (Google that please and look at the images - ugh) is becoming an ever-increasing problem, and it concerns me enough to personally want that shingles vaccine, and I believe it also might reduce the risk of other debilitating, but very common problems. For example, preliminary data also suggest these vaccines can prevent the chronic inflammation that can cause cardiovascular events like strokes and heart attacks! Look, we have come to accept the fact that COVID-19 is not just a respiratory disease, but it can also cause a CARDIOVASCULAR EVENT OR PROBLEM. In many people it can create multiple blood clots in the arteries and veins leading to catastrophic consequences. But why do we think that other systemic infections such as reactivated chickenpox/shingles or pneumococcus or influenza cannot do the same thing when it becomes more severe? It can, and it does occur in many people! Give me a COVID-19 vaccine that prevents mild from becoming severe and I bet I will show you a vaccine that also reduces the risk of cardiovascular events associated with COVID-19. I hope to see this in the next few years as more research accumulates on the side benefits of some of the more effective and safer vaccines.
I wish I would see more commercials on how vaccines, in general, not only prevent terrible diseases, but how they prevent something mild from becoming something catastrophic. I wonder how many years need to go by before vaccine preventable illnesses get better commercials on TV, or over the internet, or in my latest magazine or medical journal? Why not explain the potential side BENEFITS of vaccines and not just the potential list of temporary side effects from the most common to those that hardly ever occur in the real world? For example, young folks, and some older folks now have access to a human papillomavirus (HPV) vaccine, which appears to not only prevent cervical cancer, but may also prevent some other cancers caused in some cases by HPV, such as head and neck as well as several other cancers!
Of course, I am concerned about the potential side effects reported with any vaccine, and these need to be constantly monitored, as is the case with the COVID-19 prevention vaccines. There will be some folks that are better candidates to receive the vaccine than others. Still, as much as I love the pictures of all those folks rolling up their sleeves and getting their vaccine shots live on camera and telling us to get vaccinated, I also wish we would spend some time explaining the potential heart-healthy benefits of some vaccines and where else they have been showing promise. I understand why some people are scared of vaccines, but we need to meet that fear with more comprehensive, objective educational information. Do not take it as a threat that someone does not want a vaccine, but rather an educational challenge. People constantly weigh the pros and cons of everything, and that is in our nature to micro-dissect things. Heck, decades later we are still weighing the pros and cons of surgery vs. radiation, or long vs. short-term hormone therapy, or PSA testing or… you get the idea! People expect to hear the latest benefits and risks, so why do we think vaccine education should be any different? Educate, educate, educate, instead of just telling people they have to do something because we “experts” say they need to do it. I discuss the pros and cons of exercise almost 7 days a week with someone, and ultimately the majority that hear all the comprehensive physical and mental health beneficial data not only begin to realize the benefits exceed the risks, but they usually incorporate some type of exercise in their life. Why do we think vaccine education is any different? I realize there will always be those more compelled by the story that when a “friend” exercised it might have caused their heart attack versus the millions of heart attacks prevented by exercise. Life is a game of probability folks! The majority of people are MOTIVATED BY PROBABILITY THAT MOVES TOWARD MORE CERTAINTY but there will always be a small number of people moved by the rare and not the probable. Still, humans, for the most part, again, are motivated by probability. It is the reason we put on a seat belt, get on an airplane, or get more education, or even get married. Why do we think vaccine utilization should be treated any differently? Vaccine technology is complicated, but explainable, similar to anything else we use regularly, such as the car, refrigerator, cell phone, toilet, plumbing, big screen TV, microwave, medications, supplements… somehow we eventually learned to be comfortable with these things. It does not mean they do not come with inherent risks, but rather people began to favor the benefits over those risks. I think my generation and others that have NOT gone through previous polio outbreaks, pandemics or even epidemics have not really had all the benefits of vaccination explained to them. We also need to better explain with already published research how you are more likely to derive a benefit or multiple side benefits from specific vaccinations by personally improving your own health. For example, healthier weights, improved wellness, and heart-healthy numbers appear to improve your chances of a better response to a vaccination, and I bet that could also be the case for some of the COVID-19 vaccinations. Regardless, okay I get it - some folks do not want to be vaccinated. But most do and are welcoming it. “The preponderance of the data or evidence usually supports the verdict,” which is what I have always liked to say throughout my career. Medicine relies on the preponderance of the evidence. There will always be folks that find one paper or some rare piece of evidence to go against the plethora of scientific evidence. Big deal. Let’s take that as an educational challenge rather than an insult to our intelligence. It is one thing to be defiant despite all of the data that suggests otherwise, but to be arrogantly coercive without explaining the data is no different to me. When weighing the short- and long-term pros and cons, people usually do the right thing when the benefits for them and others are far in excess of the negatives. I believe that will happen one day soon with the COVID-19 vaccines, so this is why I lose little sleep over this issue. If the vaccines are as good as advertised, then over time, and with more novel education, they will become an accepted part of our culture. When I started in this business and I walked into a Border’s book shop 25+ years ago, there were virtually no notable objective educational books on most cancers, including prostate cancer. This was the norm and we accepted it at the time. Patient education or empowerment was virtually untapped. Today, we are inundated with wonderful cancer education options, and I am typing a column for one of many out there today that constantly do an incredible job of letting you know the pros and cons of any treatment option. We will get there with vaccines and public health. I know it.
Thank you for reading my latest installment and I wish you and your family the best of health and a wonderful safe and happy, but socially-distant holiday season.
I am concerned, of course, but I am also incredibly optimistic! I look forward to modern day science and you, of course, kicking COVID-19 and cancer in the gluteus maximus!
All of my best always,
Mark A. Moyad MD, MPH
PS. Some of the references I used in this column to help me learn something new:
Yang Q, et al. American Heart Association. Abstract TP493 Herpes zoster vaccine live and risk for stroke among Medicare beneficiaries: population based matched cohort study. Stroke 2020; 51 (Suppl 1): ATP493
Hansson E, et al. Herpes zoster risk after 21 specific cancers: population-based case-control study. Br J Cancer 2017; 116:1643-1651.
Madjid M, et al. Potential effects of coronaviruses on the cardiovascular system: a review. JAMA Cardiol 2020; 5:831-840.
Piazza G, et al. Diagnosis, management, and pathophysiology of arterial and venous thrombosis in COVID-19. JAMA 2020; 324:2548-2549.
Slomski A. Exercise intensity unrelated to older adults’ mortality risk. JAMA 2020; 324:2476.