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

Dr Trevor Cheney gives his weekly report from the Bellingen Shire Covid-19 Clinic

Dear Bellingen Shire 13 April 2021

 

It seems to pop up anywhere, without warning, esp after a gathering at the waters. It is often unnoticeable until the outbreak is almost out of control.  It is so easy to slip up on the surveillance routine or not be thorough, just once.   It needs to be jumped on as soon as noticed or it will spread rapidly and aggressively through unprotected territories.  It can be lethal, and it is ugly.

Yes, I am referring to Noogoora Burr.

No real relationship to Covid19, but it is curious how things that threaten our way of being can seem to have similar epidemic traits.  Weeds, fire pestilence, plague, militarism, corruption, and colonialism.

It’s a source of curiosity and endless poetry how in random unrelated things we find linked meanings.

Like the visual alignment of stars that bear no geographic relationship to any other part of the galaxy, yet we imagine patterns, then attribute great meaning to them, enough to influence our lives and behaviour.  Certainly it is fun to make a word picture of the constellation that is called Orion, but the simple V pattern next to him that is meant to represent a bull fighting him is a stretch.  I have never been able to put together the pattern of a dog, called Sirius, by Orion’s side.

I was pulling Noogoora burr out of the river bank while listening to an interesting radio interviewer. He enthusiastically introduced the guest with “now that the pandemic is all but over”, and went on to wax lyrically about our low unemployment rate and the onrushing recovery.  Now this unemployment number is a statistic that I take very lightly, as successive governments play games to disguise the real problem, which is underemployment.

But the claim of the pandemic being nearly done was something of a surprise, as I had been trying to understand the significance of the developments last week around the clotting risk with the certain unnamed vaccine, (which is the only one on offer to us outside some of the capitals).  The reporting of it has been urgent and with lots of contradictory sounding info.  Enough to be painted as the whole vaccination program being derailed.  Indeed chaos has loomed, while there is a 3rd and 4th wave surging in USA, India, Chile and Europe, Iran amongst other countries.

You may ask : but how is there a third wave in the USA when they have claimed to vaccinate nearly 100 million people already?  Well you can add about 32million cases so far there, and that still leaves 200million vulnerable – heaps of fresh meat for the virus.  Paradoxically some countries have been reducing restrictions prematurely on the promise of vaccine salvation, while some European countries have reintroduced shutdowns against huge protests.

You may have heard expert commentators trying to analyse the change in the thing called the risk/benefit ratio of the available vaccine in light of the recognition of the rare cases of blood clots, and recommending an extremely cautious approach, with new policies on which vaccine to give out.

How do we compare the risk of getting Covid19 today with horrible complications vs the risk of getting a horrible complication that seems to have occurred in 1 in 200 000 people? Not actually the same thing, and complex mathematics is involved that makes sense to people who did not fall asleep in their Stats classes at Uni.

Should everyone stop getting the current vaccine and wait? Should we barrel on before the big wave actually does hit us?

Just how long can we stay isolated and virus free while waiting for ”All the science” to be in beyond any shadow of doubt?

Anyway with conflicting news reports and questions about the vaccines, what has changed?

Well actually, when you strip off all the noise – not a lot!

In fact the new debate stripped down is a triumph for the concept of science that I have tried to explain many months ago, when conspiracy theories were going nuts. Science constantly questions itself and adjusts the theory as new information comes in.  Cultists and conspiracy theorists by definition can’t, They lock on like a Staffordshire terrier and will hold  on to the death of themselves or the subject.  Once again we have Renaissance Vs Jonestown.

So pushing aside the noise and looking down on reality:  There is still a global pandemic, and in some areas it is surging up again.  Indeed it is surging virtually out of control just a couple of km from Australia’s border – in PNG.   On Sunday there were 9 cases of Covid19 in NSW – all returning travellers – that is not going to stop.

We are all getting pandemic fatigued.

So firstly let’s do a little coagulation 101 to help understand the words in the news.

As mentioned I was finding some of the reports confusing.  It sounded like having too few platelets is causing some people to clot.

Blood flows through your arteries and veins with vital oxygen and nutrients and water for your whole body.  But, if a vessel is damaged, you have evolved a spectacularly elegant means to limit the loss. Firstly, the vessel has tiny muscles that spasm to contract the width of the damaged vein or artery for about 30-90 minutes.  (Often just enough time to get to the emergency department where we pull the bandage off and get squirted!)  Then platelets, which are more like blob fragments of cells rather than full cells, get stimulated by “hurt” chemicals and virtually invert from a smooth blob to a spiky see urchin – a bit like Gremlins in the 90s movie.  The spiky, sticky platelets get caught up and clump while an elegant, expanding cascade of reactions start trapping red blood cells and stringy chemicals floating in the blood to form a blanket over the plug of platelets.

All this is regulated. Even while a clot is forming, the body starts the process of breaking it down,  even in a fully blocked vein – drilling a tunnel though  the blockage.  Meanwhile the vessel is repaired or a new one grows past it.

Obviously, ideally, you want the vessel repair to be perfectly timed as the clot is cleaned up and blood flows again.   Ideally!

Sometimes the platelets are just not enough so the blood doesn’t clot – causing bruising and ongoing bleeding. Sometimes they get all used up  – in some surgery or multi trauma, eg car crashes or catastrophic bleeding at child birth –  and we need to replace them.  Some unlucky souls seem to develop an allergy to their own platelets where the immune system produces a chemical, an antibody, which binds them and takes them out.

So it seems currently the foremost hypothesis to explain the newly coined term “Thrombosis and Thrombocytopenia Syndrome”, is that  an antibody hits the platelets and causes them to clump up for no reason in unusual places, thus using them all up – hence the thrombocytopenia (or platelet deficiency).  Indeed in some of the patients an antibody against platelets has been found, but it is not universal and not clear if it is the “link”.  This condition is is still very rare.  There is a lot of research to go to get us a better explanation, and why after vaccination.

It seems TTS mostly occurs in younger people.  So the Immunisation experts have set an arbitrary recommendation for people over 50 to go ahead with the currently available vaccine (the one invented by Oxford University – In fact that seems to be the only one we will get for quite a long time).  They picked this number to have a big safety margin.  Yes, it is an educated guess. Plus some clever maths again.

But should we wait until other vaccines come available, since the risk of getting covid19 right now is so low? Australia does not have an active epidemic?

Working through this I cannot help but reflect on what happened before Easter in Brisbane and Byron Bay. The outbreak was in a NSW town within a week or so of being noticed in Brisbane.  It was stopped by good luck and good (horribly painful) decision-making.  A bit like putting painfully heavy pressure on a gushing artery.

BUT the effectiveness of the vaccines does not really pick up till about 10 -20 days.  We are warned that you are NOT protected from Covid19 as soon as you have the vaccine.  People have walked out of vaccine clinics and into a sneezer the next day in the USA. So unfortunately the idea that we could wait till there is an outbreak, and that will change the theoretical risk /benefit ratio, potentially is dangerous logic.  There may not be time.

And winter is coming.

These viruses generally spread better in winter.

So after much logical and scientific consideration,   The Australian Technical Advisory Group on Immunisation still advise that anyone over 50 get vaccinated, as soon as your turn comes up, with the Oxford invented vaccine.

If we do get other vaccines available, and their safety profile holds up, then they will recommend getting the other vaccine into younger folk (think 49 = young!!!).  If anyone under 50 is comfortable with this real, but very small risk , then we should not hesitate to offer the vaccine we have.  It is otherwise safe and effective.   Covid19 infection is not.

And really — I am really happy with this slightly modified advice, ‘cause otherwise not much else has changed from weeks or months ago, except outside our window the weather is looking even dirtier!

So it is exciting to note that most of the practices in the Shire now have received a starting supply of the Covid19 vaccine and some have already started to administer it.  We are keen to get it out.

There are logistical issues around how we have to handle these vaccines and we can only have them drawn up and out of the fridge for a short time.  So most of us will want to do focussed, efficient Covid19 vaccine clinics – Please talk to your own practice.  And I think it is safe to say for most of us GPs we will be advising that if you have other issues, it is best to make separate appointments.

If you have more questions you are invited to call the National Coronavirus and Covid-19 Helpline on 1800 020 080.

Oh,  and back to random links – Given the other big news of the week giving pollies a break, it is curious to recall that King George VI died of a clot – in a coronary artery.  And in the week where 1 terribly unfortunate person in Australia had a suspicious blood clot after the vaccine, there were about 7 stabbings per day in NSW – about 2820 per year. Ah, just random association.

I found a new term from the last week of “C “ to reflect how our news is currently distributed.  “Compulsive Chaotic Catabolic Controversy Curation”.

 

Please remember, this is just one perspective on the progress of a real pandemic and, rather, check with your own GP who is probably also wishing this was all over, and of course all the government websites.

Dr Trevor Cheney.

 

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