Weekly Report from the Bellingen Covid-19 Clinic: Dr Trevor Cheney

By April 27, 2021 In Focus 4 Comments
Dr Trevor Cheney gives his weekly report from the Bellingen Shire Covid-19 Clinic

Dear Bellinger Shire

27th April 2021

 

I started writing this letter to address some of the misinformation and noise around Covid19 , on the basis of cleanly defogging and  interpreting the information as  I saw it emerging, and (more importantly)  changing.  I was concerned that a lot had changed over this last weekend.  There have been some more cases of the rare clotting disorder “Thrombosis with Thrombocytopenia Syndrome” now confidently linked to the Astra Zeneca Vaccine, even though we don’t know why.  It has made our experts dig deep into the data to ensure the vaccine program is still the best plan, and come up with new recommendations.

Then we had another outbreak in WA.  In reality this juxtaposition reinforces what I was trying to explain last week, and to a number of folk in conversation since then.

Yes, there is a real but rare and serious complication of the particular Covid19 Vaccine that we are using, although there are isolated reports of a similar phenomenon even more rare with the Pfizer vaccine.  If only we could not see the outside world, and only had to deal with the state of the epidemic in Australia, the clever statistics available from the specialists advising government show that vaccinating younger folk when there is almost no transmission in the Australian community does not stack well.

There is a clever slide graph on the Dept of Health Website (which I expect is open to the public) showing that as one gets older the seriousness of the disease gets worse while the risk of a reaction gets markedly less, so the benefit of vaccine increases way past any risk for an older person.  Conversely looking at younger ages – when there is no community transmission – then the risk of vaccine side effects relatively outweigh the benefit. The switch point in the numbers occurs at age 50.  That’s why we have been told to keep the AZ vaccine for those over 50.

That is, if there is no community transmission.

However all that changes if, or more likely when, an outbreak gets away.

Suddenly the risk vs benefit ratio shifts.  They have compared the statistics if we had another Melbourne style outbreak (modest and small by world standards now), and even at that level the scale of risk slides down and the benefit of our current to a younger person far outweighs the risk. Indeed, there are plenty of informed younger frontline health workers looking down the barrel of their own risks from the disease when an outbreak comes.  And they are sweating on getting a vaccine.

If we get a UK style outbreak, the risk posed by a vaccine is barely worth thinking about.  Even so they have reported 168 confirmed cases of the TTS in the UK.  That is in the context of   >46 million vaccines administered, >33.6M of them being first dose, and >21.3M of those being the same vaccine that we have available.  So the new data there suggests about 8 per million people have had the rare clotting effect – a little more than previously, though the feared mortality rate is dropping.  This against >127,000 people have died of covid19 in the UK, not all old, and their economy is reeling.

So once again has the ground shifted?  Not really. India is having its terrible third wave and as of the weekend the official toll is 195,000 fatalities, rapidly rising and suspected to be a gross underestimate.   Beautiful resilient Lithuania on the Baltic sea with a population of only 2.79Million has already lost 3848 people .  Sweden, to which I have often compared NSW in population and development (though I think in many ways they are well ahead of us) has now had nearly a million cases and lost about 14000. That’s equivalent to the whole of the Bellingen Shire. This is our future until we achieve a good level of immunity.

The future of “living with covid19” as some publicity attracting politicians like to spruik, actually depends on us getting vaccinated as soon as possible.  I found it curious this week seeing some doctors writing in opinions to medical newspapers that the WA outbreak shows we should just hunker down and keep our borders closed indefinitely, assuming that will protect us.  Sadly, that strategy is about 400 years too late.

There is a nice irony appearing.  Last year young folk were distressed and stating that they were being asked to sacrifice their future and present to protect the older vulnerable population. Well now we’ll flip the responsibility and are asking all over 70s to step up and get vaccinated asap to get out of danger and protect the wave of younger folk who will also be needing vaccination in a hurry.

Good news : There was an article last month in  the Lancet (premier world medical journal from the UK)  looking at the frequency of neurological  deficits –ie brain damage –  post Covid19.  Now there has been a bit of anxious watching on this.  In the 1919 Influenza epidemic, there followed a sudden and widespread incidence of a form of Parkinson’s disease in young people.  You can look up Parkinson’s disease if you’ve never heard of it, or you can also see a memoir by the comedian Billy Connelly who is dealing with it.  Even better you can go to the video store and order the Robin Williams movie -”Awakenings”, which describes the first modern successful treatments for Parkinson’s disease pioneered in those pandemic victims.

Once again Covid19 is not Influenza.  It is much worse.  But the potential for organ damage when there is an overwhelming infection is comparable.

Anyway, the British team following this concern is NOT seeing an increase in Parkinson’s disease or similar neurological syndromes.  This is relief.

We have been asked why blood clots are not a risk for over 50s, and why someone who has had a previous blood clot is still encouraged to have the vaccine that has been reported to be linked with blood clots. Well there isn’t a straight answer.

In Medicine everything is on a spectrum.  Firstly regarding the age:- risks change on many things with age.  Most familiar forms of blood clots are actually more common the older you are.  Blood clots occur too frequently in someone over 80 with an irregular heart rate (called Atrial Fibrillation), triggering a formula we use to prescribe “blood-thinning” medications.  But it doesn’t stop someone 79 with AF getting a clot that could cause a stroke. We need to start somewhere and then flex our advice for the individual.  There has been a case of a person over 50 with the TTS clotting, but that is in the context of the UK targeting many more of their over 50s, and so the proportionate incidence of this side effect is actually vanishingly small in the older age group.

Our immune systems are very aggressive when young and then start to wane, or forget their response, as we get older.  Some things are good to forget – like allergies, old relationships and stupid things we did as teens.  This is not absolute.  I have dealt with many people developing sudden inappropriate immune overactivity – allergy or autoimmune disease, in their 70s.

But initial data suggests that TTS seems to be an immune response to some aspect of the disease that may be misdirected against the platelets that have a pivotal role in protecting us against bleeding.  So the reactivity is going to be stronger when you’re younger.

Again not all clots are equal.  Every disease system we know has subgroups and a variety of causes.  Drilling down past the presenting symptom is a cornerstone of modern medicine.  There is an old Australian film set in the 19thcentury – “ We of the Never Never” (set in Northern Australia not Gleniffer) in which is a dramatic scene of a protagonist desperately sick and probably dying.  Another character declares with ominous portent. “It looks like FEVER!” as if that is the diagnosis.

Well, people with fever (ie feeling hot to touch, then shivering and complaining of feeling cold) did die often back then.  But we now know that fever is a symptom of thousands of maladies.  We want to know what is causing the fever.

Then doctors recognised pneumonia as a cause of fever.  But pneumonia (or pneumonitis) can be caused by chemicals (bush fire smoke), or bacteria (pneumococcus for which we vaccinate over 65s), or viruses (for which we have no real treatments) , or fungus (inhaled from compost or from smoking damp or poorly dried pot) , or even one’s own bodily fluids in the wrong place (partially vomiting then inhaling the vomit when very drunk or unconscious or weak).  The why really matters because it forms a basis of how we can treat the condition.

And so it is with blood clots.  Lots of different reasons for what looks like the same end results.  The TTS is a different take on clotting.  It has a different cause and will need a different treatment.  So far the evidence suggests a past history of blood clots has no bearing on the risk of this complication, younger or older.

Back to the future. What can we do to recover that sense of purpose and shared place in society that many young folk are saying they feel with their job, uni, and housing, even environmental survival prospects thrown up on the air?

Professor Pat Mcgorry – a multi awarded and forward thinking psychiatrist, is very worried about that feature at present.  He describes a parallel pandemic of youth mental health.

Talking about solutions with our under 30s is going to be vital.  They are clever.  We are still at potentially a pivot point in our culture that could be made positive. We need to engage with anyone feeling the pressure of current events and invite them to engage in the community. It helps to set examples. Remember all the lock down resolutions of changing your life, getting back to what’s important?  Have you made a shift yet?  I know I’ve harped on this twice before.

Giving and being engaged in the community is a powerful predictor of happy longevity for young and old. There is the local show season coming up and the organisers are looking for volunteers, participants with entries, attendees….

 

Please remember this is all just one perspective of the emerging information and avalanche of government advice  – into which you are invited to delve.  Please check any detail with your own well trained and carefully differentiating GP as they drill down into the real cause of the symptom and apparent dread diagnosis that Dr Google has thrown up for you.   And get along to, or into, stuff with young adults in your life.  If you’re a young adult, enter stuff and drag along the oldies out of their torpor.

 

Dr Trevor Cheney

 

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