Should COVID-19 Vaccination be Delayed in Survivors with Serum Antibodies?

 

If you’ve had COVID-19, the one uniform recommendation from CDC is to wait at least 90 days if you’ve received treatment with monoclonal antibodies or convalescent plasma.  For other COVID-19 survivors, some Medical Centers recommend receiving the vaccine within weeks after infection while others suggest waiting up to several months.

Yet, there remains a national shortage of the currently approved (Moderna and Pfizer) vaccines.  This issue will hopefully be resolved later this spring pending Johnson & Johnson’s application for emergency FDA approval using their single dose vaccine; they expect to supply 100 million U.S. doses by June.  The J&J vaccine looks especially promising not only because of its single dose, but also because of storage capability (simple refrigeration) and vaccine stability (at least 3 months).  Most impressive however, is the ~85% reduction in severe COVID-19 cases (hospitalization and COVID related deaths). Compared to earlier vaccination trials, J&J’s Phase III study included more severe COVID-19 cases with benefits extending beyond the U.S. to the U.K. and most notably, South Africa, where COVID-19 variants have raised concern re: viral transmission and vaccine effectiveness.  In other words, until the J&J vaccine is approved and ready for mass distribution, the overall supply chain is hampered. Hence the question….

Should COVID-19 Vaccination be Delayed in Survivors with Serum Antibodies?

A recently well-designed study (https://science.sciencemag.org/content/early/2021/01/06/science.abf4063) is consistent with this idea because they found immunity to persist in 95% of affected individuals for at least 5-8 months following infection.  Another study of 3 million individuals that had COVID-19 antibody testing (currently in preprint; https://www.medrxiv.org/content/10.1101/2020.12.18.20248336v1) found that only 3 out of every 1000 became reinfected 90 days or later after the initial infection as compared to 3 out of every 100 who tested positive for the first time.

The real question in the setting of current vaccine shortages, is how can we best prioritize vaccination for those who had COVID-19 more than 3 months ago?  A logical approach would be to check for antibodies using a reliable, commercially available test (such as performed by Quest or LabCorp).  This past week, I saw a patient who experienced COVID 4 months ago, for which hospitalization and high-flow oxygen treatment was required.  Yet on antibody testing this week, we were surprised to find out that he tested antibody negative.  He is now on the vaccination list.

Owing to current vaccine shortages, the CDC should consider recommending antibody testing for COVID-19 survivors beginning 3 months after initial infection with repeat testing monthly (or bimonthly).  If serum antibodies continue to be present, vaccination should be delayed in order to permit others without natural immunity, to move ahead of the line.  With more than 25 million COVID-19 survivors in the U.S. (whose rates of reinfection are exceedingly uncommon), why not prioritize vaccination to the millions of high risk men and women who do not have a known history of COVID-19?   Having recently recovered from COVID-19, this is how I plan to proceed.

Michael Miller, MD is Professor of Medicine, Epidemiology & Public Health at the University of Maryland School of Medicine in Baltimore, MD.

 

Paying Homage to “Hammerin’ Hank”: One of Baseball’s All-Time Greats!

If you love baseball like I do and grew up during the ’60s and ’70s, you would have known that New York and Chicago were the 2 best cities to live in because both had National and American League teams.  Growing up in the “Big Apple”, I had the good fortune to see some the greatest players of the generation.  At the original Yankee Stadium, I saw the veteran Whitey Ford outlast a young pitcher named Tommy John (yes, that Tommy John) and Mickey Mantle smash a line drive single after multiple strikeouts.

However, I was a die hard National League fan and always favored the underdog, in this case, the bumbling, stumbling, NY Mets.  During the early years , our combined trip to the World’s Fair followed by a game at neighboring Shea Stadium, was always fun though never a win. But soon after my favorite player, Cardinals 3rd Baseman Ken Boyer, was traded to the Mets and a number of talented players were drafted or acquired through lottery (think Nolan Ryan and Tom Seaver), the team took off to “amazing” heights!

Taking subway excursions to Shea Stadium, I got to see many great players in action but took particular interest in Hank Aaron as he drew closer to Babe Ruth’s all-time home run record of 714.  During the summer of ’73, we went to see the Mets vs the Braves.  Aaron did not disappoint, launching 2 towering home runs (#695 and #696)…. for their part, the Mets veteran superstar Willie Mays, could only muster a double.  After the game and just for kicks, I sent off letters to a bunch of hall-of-fame credentialed ballplayers seeking an autographed ball.  Over the next several months, I received 2 autographed baseballs and one of them was from Hank Aaron!  It’s pretty amazing to think that with all of the pressure, scrutiny, prejudice and threats (against him and his family) that he had to endure, he was kind and generous enough to send me a ball.  Needless to say, I was super excited when he hit home run number 715 the following spring.  It was particularly meaningful to me because the pitcher who threw Hank’s home run ball was Al Downing; just a decade earlier Al had also thrown the grand slam home run pitch to Ken Boyer, that helped to lead the St. Louis Cardinals to World Series victory!

I was saddened to hear of Hank Aaron’s passing this past week.  He was one of baseball’s all-time greatest, not only for his natural and gifted athletic prowess, but also because he maintained his poise and graciousness even after his home run title was surpassed during the steroid cheating-era.  He will be sorely missed.

Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland USA and located across the street from Babe Ruth’s birthplace.

 

 

 

Paying Homage to “Hammerin’ Hank”: One of Baseball’s All-Time Greats!

If you love baseball like I do and grew up during the ’60s and ’70s, you would have known that New York and Chicago were the 2 best cities to live in because both had National and American League teams.  Growing up in the “Big Apple”, I had the good fortune to see some the greatest players of the generation.  At the original Yankee Stadium, I saw the veteran Whitey Ford outlast a young pitcher named Tommy John (yes, that Tommy John) and Mickey Mantle smash a line drive single after multiple strikeouts.

But I was a die hard National League fan and always favored the underdog, in this case, the bumbling, stumbling, NY Mets.  During the early years , our combined trip to the World’s Fair followed by a game at neighboring Shea Stadium, was always fun though never a win. But soon after my favorite player, Cardinals 3rd Baseman Ken Boyer, was traded to the Mets and a number of talented players were drafted or acquired through lottery (think Nolan Ryan and Tom Seaver), the team took off to “amazing” heights!

Taking subway excursions to Shea Stadium, I got to see many great players in action but took particular interest in Hank Aaron as he drew closer to Babe Ruth’s all-time home run record of 714.  During the summer of ’73, we went to see the Mets vs the Braves.  Aaron did not disappoint, launching 2 towering home runs (#695 and #696)…. for their part, the Mets veteran superstar Willie Mays, could only muster a double.  After the game and just for kicks, I sent off letters to a bunch of hall-of-fame credentialed ballplayers seeking an autographed ball.  Over the next several months, I received 2 autographed baseballs and one of them was from Hank Aaron!  It’s pretty amazing to think that with all of the pressure, scrutiny, prejudice and threats (against him and his family) that he had to endure, he was kind and generous enough to send me a ball.  Needless to say, I was super excited when he hit home run number 715 the following spring.  It was particularly meaningful to me because the pitcher who threw Hank’s home run ball was Al Downing; just a decade earlier Al had also thrown the grand slam home run pitch to Ken Boyer, that helped to lead the St. Louis Cardinals to World Series victory!

I was saddened to hear of Hank Aaron’s passing this past week.  He was one of baseball’s all-time greatest, not only for his natural and gifted athletic prowess, but also because he maintained his poise and graciousness even after his home run title was surpassed during the steroid cheating-era.  He will be sorely missed.

Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland USA and located across the street from Babe Ruth’s birthplace.

 

 

 

Secrets to Successful Cardiovascular Aging

 

This past week, a state-of-the art review entitled “Cardiovascular Aging and Longevity” was published in the Journal of the American College of Cardiology. As I was reading this article, I was reminded of the Annual Centenarian Luncheon Day that was launched by my colleague, Dr. Odessa Dorkins in the early 90’s.  Dr. Dorkins organized a yearly celebration for Centenarians where families were brought together throughout the greater Baltimore region. Back then, there were ~100,000 men and women worldwide who had attained the age of 100 (or older) with numbers that grew to more than 500,000 by early 2020.  Unfortunately, COVID has hit our seniors (ages 80 and above) the hardest and as a result, we are unlikely to see growth rates within the elderly population increase to recent levels for quite some time.

In 1995, I had the opportunity to participate in the luncheon and was blown away by the Centenarians and their families.  For one, the vast majority exhibited good (if not, very good) cognitive and cardiovascular function, with many still active, notwithstanding physical ailments.  Perhaps even more impressive was a shared feeling of optimism and overall positive outlook, despite many losses of friends and loved ones over the decades.  Many were highly spiritual and prayed daily, most were socially engaged with solid support networks and the overwhelming majority lived “clean” lives (minimal alcohol or smoking history). They said that while they enjoyed food, they rarely overate.  Even though these Centenarians did not live in the “Blue Zones”, so-called communities with exceptional longevity, such as Okinawa, Japan, Ikaria, Greece and Nikoya, Costa Rica, they illustrate that successful cardiovascular aging can exist in major U.S. cities and most of the world. Listed below are  5 secrets to successful cardiovascular aging shared by “youthful” Centenarians and those living in Blue Zones that we can put into daily practice…with a little luck it may increase our odds as well!

1. Mildly Restrict Caloric Intake: Japanese Okinawans, among the first of the Blue Zone groups identified with healthy longevity consume 15-20 percent fewer calories compared to the average dietary intake in Japan.  If your caloric intake approximates 2000 kcal daily, try eliminating 300-400 calories (example: 1 plain bagel with butter equals 350 calories).
2. Drink Coffee and/or Tea: Both products are fortified with antioxidants, reduce inflammation and improve vascular function.  Moderate intake of as little as 2 cups daily has been shown to improve cardiovascular aging.
3. Increase Exercise: Moderate activity (example: walking at a pace of 3-4 miles per hour) improves 3 major risk factors, blood pressure, blood glucose and blood fats (triglycerides). Recent studies also suggest that physical activity slows aging by fueling the enzyme that maintains telomere length.  Telomeres are genetic “protective caps”; the longer the telomere the slower the aging process.  For example, long healthy telomeres are more commonly found in athletes and the physically active whereas telomeres tend to shrink more rapidly with a sedentary lifestyle.
4. Reduce Emotional Stress:  Daily stress that is not managed effectively also raises the risk of telomere shortening.  Studies are beginning to emerge that activities that reduce emotional stress, such as yoga may also maintain telomere length and reduce cellular aging.
5. Quit Smoking: It’s fair to say that you won’t find a lot of smokers in Blue Zones (otherwise they would be Gray Zones).

Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland USA and author of “Heal Your Heart: The Positive Emotions Prescription to Prevent and Reverse Heart Disease“ published by Penguin Random House.

4 Reasons to be Optimistic about COVID in 2021

With the COVID-19 pandemic serving as the most physically and emotionally distressing health event of 2020, there are a number of reasons for optimism that new treatments for COVID will improve overall health and mental wellness in 2021.  Because optimism in general may improve heart-health through better nutrition and sense of well-being, it stands to reason that starting the season with an optimistic disposition especially as it relates to conquering COVID is likely to pay off healthy dividends for your heart and overall health.  Here are 4 reasons to get excited that COVID will soon be behind us.

1. COVID Vaccines are here.  Yes, I know that vaccinations got off to a slower start last month than projected, but now with nearly 6 million in the U.S. receiving the first dose of the Pfizer or Moderna vaccine, these numbers are expected to increase rapidly after President-Elect Biden assumes office later this month.   Later this quarter, we anticipate emergency approval of additional vaccines that include the single dose vaccine from Johnson & Johnson.
2. COVID antibodies last longer than previously thought.  For those who have recovered from the virus, a new study suggests immune protection for at least 8 months!  This is particularly encouraging if you are not among the priority groups for vaccination and may have to wait until later this spring/summer.
3. Antibody infusion therapy reduces the need for hospitalization.  If you have recently been diagnosed with COVID, this therapy may be useful for you.  It received emergency approval from the FDA in late November for mild-moderate COVID symptoms but you would not qualify if you require oxygen treatment or hospitalization.  The procedure takes a couple of hours and has been shown to reduce hospitalization rates by 70% as well as shorten the overall duration of illness (see my previous blog, “My Bout with COVID”).  There have been reports of significant improvement in fatigue, muscle aches and even restoration of taste and smell soon after receiving this therapy.
4. Plasma Exchange may reduce lung-related complications if given early.   Another new study found that in men and women aged 65 and older, convalescent plasma (plasma donated after COVID recovery) was associated with a near 50% reduction of severe lung disease that would have otherwise required oxygen therapy.  The key finding here was that plasma exchange had to be undertaken within 3 days of symptoms.  In addition, those receiving plasma with the highest antibody titers also had the greatest likelihood of success.   Use of plasma exchange and antibody infusion therapy is only effective during the early stages of the disease as other studies have shown that hospitalized patients do not reap these benefits.

I don’t know about you, but I am optimistic that we will not be talking about COVID in 2022!

Michael Miller, MD is Professor of Cardiovascular Medicine at the University of Maryland School of Medicine in Baltimore, Maryland USA.  To improve your heart health, check out his latest book:  “Heal Your Heart: The Positive Emotions Prescription to Prevent and Reverse Heart Disease“ published by Penguin Random House.

My Bout with COVID

After writing numerous blogs throughout 2020 on ways to protect yourself from COVID-19, the cruel irony was being diagnosed with COVID last month.   But in my case, COVID was not transmitted in the hospital setting. Even though I was treating COVID patients, all precautions were taken and I was well protected.  Nor was COVID transmitted through travel or attending social engagements during the Thanksgiving holiday weekend as we were non-participants.  So how did COVID reach our household?  We are still mystified.  One day, my wife experienced a rare headache, fatigue and chills and was diagnosed with the virus.  As the only other occupants in our home, my son and I tested negative and we both self-quarantined.  It was suggested that we retest 5 days later (the amount of time it generally takes for the virus to replicate in the body and become infective). My retest came back positive, although I had minimal symptoms initially (my son remained COVID negative). 

What makes COVID-19 so tricky (and elusive) is that if you lack or have very mild symptoms, it is very easy to spread the virus to others. For example, I never experienced a cough or shortness of breath; my only early symptom was mild fatigue that could have easily been explained by not having a good night’s sleep.  That is why it is critically important to self-isolate if you have been exposed to someone who is COVID positive until you are cleared (7-14 days) by your local health department.

While my wife fortunately recovered within a week of her symptoms, I began to experience severe body aches, fevers and fatigue.  To neutralize the virus, I qualified for and received the monoclonal antibody treatment. This is the treatment that  President Trump, Dr. Ben Carson and others have received. Immediately after treatment, my body aches resolved and I was well on my way to recovery.

Monoclonal antibody therapies from Regeneron and Eli Lilly have been shown to reduce COVID symptoms (depending upon viral load), speed of recovery and most importantly, lower hospitalization rates by up to 70%.   I have referred my patients with significant COVID symptoms who qualify for this therapy to our Johns Hopkins/University of Maryland infusion center in Baltimore.  Infusion centers are located throughout the U.S. with infusion taking 1 hour for the Lilly therapy that I received followed by another hour of monitoring.  Unfortunately, those who require hospitalization (low oxygen saturation levels, for example) do not qualify for this outpatient procedure. 

Until a high proportion of the population is vaccinated, we now have at least 1 proven therapy that reduces hospitalization rates for COVID.  However, while the U.S. government through Operation Warp Speed has funded this therapy at no cost to those who qualify, it remains vastly underused.  Should you have COVID and symptoms within 10 days of the diagnosis, be sure to contact your physician to determine whether you may be a candidate for antibody therapy.  It can make a big difference in your recovery from COVID.

Wishing you a Happy New Year and COVID free 2021!

Michael Miller, M.D., is Professor of Cardiovascular Medicine, Epidemiology and Public Health at the University of Maryland School of Medicine in Baltimore, Maryland, USA.