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

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

Dear Bellinger Shire, 6 October 2021.

 

So it’s all about to change.

In days of yore in Medicine before there was much knowledge, technology, evidence, standards, successful treatments, cures etc and when the life expectancy for most around the world was 50-60, Physicians would talk about a “deflourescence”.    (In Australia in the 1890s natural life expectancy for a boy was 47 and girls 50! According to the Australian Institute of Health and Welfare in Canberra).

A person would take ill with a fever, have rigors (feeling very cold and frightened, shivering in waves, and then suddenly get flushed, hot and throwing off covers, only to go under again), and then either the fever would “deflouresce” – hooray,  yippee! (but no inheritance yet).  Or they would succumb.

Apparently this week celebrates the 150-year anniversary of George Elliott, a pioneering incisive English novelist and modern thinker responsible for the much-lauded book  “Middlemarch” (which I confess I have not read yet).  She had kidney disease – thus some immune suppression – caught a simple throat infection and succumbed to the fever – aged 61.

It feels a bit like we are moving into a communal “deflourescence” – soon.

As a society we will be a bit changed, but we won’t communally succumb.

We are approaching in NSW the point where our Government will no longer hold the state in tight movement controls based on the fact that >80% of over 12 year olds will have as good a protection against Covid19 serious infection as they can get, and the society can no longer hold back.

I did hear some statements from a particular govt. minister last week that sent some expected chills down the spine.  He stated that there will still be some controls with masks and proof of vaccination status etc, but it will be almost entirely up to business owners to police them. Those of us who run small businesses have been trying to work though that issue and it is not at all easy in the charged arguments that people want to start about the pandemic.  But then again if 80-90% of our populations have turned up for vaccines it is a shrinking minority still wanting to take issue.

People still have rigors and it is an indication of some severity of an infection.  But we have much better ways of working out what is the cause and then applying some pretty good treatments.

We’re almost at that point with Covid 19 with encouraging phase 3 trials of a medication that uses a combination of “monoclonal” antibodies.  Now I’ve mentioned before that you may hear more of that term.  It is not a statement of boring antibodies, or that they are taken from monocles, or the cloned sheep “Dolly” – (nor some underground warehouse of cloned people being held for research).

When you make an immune response to some disease, you may turn on more than 1 set of cells that respond to more than one spot (epitope) on the invader.  So the serum in your blood may contain “polyclonal” responses.  Unfortunate people who develop leukemic diseases will have one cell line go nuts and their blood will be overtaken by a monoclonal, i.e. just one clone, of a particular cell which crowds out that lovely diverse mix which is your blood cell population – just like diversity that works all through nature, and should work in our human institutions.

Monoclonal antibodies as a medicine are being increasingly made (using altered yeast or similar cells) to produce that 1 antibody type to target one specific disease and hopefully have fewer side effects.

Last month in the British Medical Journal was reported very encouraging results of a phase 3 trial of a combination of monoclonal antibodies to be used to prevent deterioration of a patient with a new progressing infection.  The rate of bad outcomes was about one third of the control group.   Not available to us locally for a bit yet, but here’s hoping.  The manufacturer sponsored the trial so some rigorous reviews still to go.

Some of my feed has reports from frightened immunocompromised folk who are still at risk as they may have had less potent response to vaccines.  Just to clarify – people with immune suppression are not at risk from the vaccine – they are at higher risk from the infection,  but they mount less of a response to the vaccine.  Some of the articles suggest they may get only 40% of the protection the vaccines give the average person.  They may be first in line for any booster trials next year.

Covid19 mortality rates in Australia seem to be dropping, and experts recognise this as a vaccine effect at last. Once again I must repeat nothing is perfect and yes someone at the coffee shop may point out that there have been some cases of vaccinated people getting sick – but that is much rarer.  The vast majority of the 295 Australians in ICUs are still those who have not had access to a vaccine.  Once you’re in hospital it is a bit too late.

In your local and regional health systems we will be carefully adapting to the changes in health orders – with not a complete abandonment of caution.  In hospitals (and medical practices) we have vulnerable people.  We will not want unmasked or mildly symptomatic people shedding virus in our airspace.  We will be wearing facial protection for a longer time to come yet, and in our Primary care clinics we will maintain requirements for wearing masks.

Coming is a time of some uncertainty.  There are some glossy claims about life in Europe being normal – I suspect that is wishful thinking.  Countries around the world will be redefining what normal means now as the disease becomes endemic – (that means constantly in the community and popping up every now and then in little epidemics or outbreaks).

A patient in the ED asked why I was wearing full PPE and looking concerned.  Back to some simple maths-:  We will be very relieved with our community getting to 80 or 90% vaccination protection.  But just in the Coffs Region that still means 10-20,000 still not protected.  There is a way to go as the virus moves though the whole population, and we still fear being swamped.

I expect health planners are particularly concerned about QLD and WA.  Their vaccine rates are much lower.  I am particularly happy that all my family in QLD, who we are so aching to see just like everyone else, are all fully vaccinated.  There are large pockets of hesitancy or lethargy on this issue still in QLD so please if you have family and friends up there it might help to remind them that the borders and restrictions are going to lift before long. They need to catch up.

A lot of reports about people living with disabilities still having lower rates of vaccine access– Do you know anyone who would fit this description? And how can we help to get them the same level of protection?  We no longer have a supply problem.

A bit of disappointment -: A Hospital team reported in the European Journal of Clinical Nutrition  (July) they tried treating Covid19 patients entering ICU with high dose vitamin D injections.  They found NO improvement in outcomes or severity.  Other studies keep finding a correlation between low vitamin D levels and worse Covid19. The controversy remains, and the “anti” argument suggests that low vitamin D occurs coincidentally along with other conditions that are higher risk, like malnutrition and Diabetes.  The jury is still out.

My old Boss in education argued that young people argue most for change but at the final signing are often the most resistant to it – perhaps it is hard to let go of everything you have just worked so hard to learn.  But then he may not have understood the agility of Millennial + generations whose world is moving much faster than us preceding are able to comprehend.

Either way the Journals are full of rising rates of mental health challenges in teens and young adults after this 2 years of shifting sands.  In reality humans have endured big changes forever and adapted – that is why we occupy almost every niche in the planet.

The conversations we need to be having with our future is to be alert to, and engaged with, change.

When I was practicing obstetrics, one of the most important conversations I could have with a couple just before and just after their baby arrived is that everything you know will change.  Fight it and parenting will be more painful than it needs to be. Roll with the changes, adapt, to find the best in your new life and  your resources will grow at pace with your community nurses’ measurements. Can we do this as a community as we are delivered of this very different evolutionary worldwide event?

At the least “aspiration” to see a better life and planet is great.  But unfettered consumerism is a perversion of the human need for aspiration.

Please keep in touch with the changing (relaxing) State Health regulations- The Bellingen community support group clarifies it for us = thanks so much to their efforts.

 

And as this is just one perspective on the pandemic of life, check any detail with your own GP, who no doubt is fangin’ for a change in the pressure, the options, the confusing messages too, but whose life study is in how to change bad outcomes to good.

 

Dr Trevor Cheney

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