Health and Wellness Update from Dr. Leonard Valentino About Vaccines, Hesitancy and Understanding VITT

COVID-19 and the pandemic continue to dominate the news cycle for most Americans, although many of us would like to think about baseball rivalries, whether we choose to see Water Man or Silo this weekend in the local movie theater, or the competition between Manchester United and Manchester City (the later holding a substantial 13 lead in the Premier League standing). It’s true that the US is doing a bit better in terms of new COVID-19 cases with about 40,000 reported on May 4^th (be with you). This is unfortunately not the case across the globe, with nearly one million new cases diagnosed each day- 382,000 of those new cases in India alone. The medical and humanitarian crisis unfolding in India may seem so distant from our front doors but if not controlled will impact all of us.

What We Can Learn From the Crisis in India

The coronavirus that causes COVID-19 is an RNA virus. Viruses, including coronavirus have short generation times (the time it takes for the virus to copy itself) and therefore have relatively high mutation rates (copying errors), about one mutation or more per cycle of replication. Currently, there are at least 13 defined variants or mutant coronaviruses globally. One of these is a variant called B.1.617 which has accumulated more than a dozen mutations! This variant, which first appeared in October 2020 and is now the most common variant in India, has triggered a second wave of COVID-19 cases in the country. It has been detected in at least 17 other countries including in the United States. This variant has a shorter generation time, meaning it replicates faster than other variants, potentially leading to additional new mutations and may also have increased ability to spread. This variant has been called an “escape variant” because infection with these mutant virus strains can be dangerous for people who have been fully vaccinated and for people who have recovered from COVID-19 infections. The need to continue to follow CDC guidelines (Guidance for COVID-19 | CDC) remains key to staying healthy. Avoid large events and gatherings, when possible. Consider the level of risk when deciding to attend or host an event. Promote healthy behaviors and maintain healthy environments to reduce risk when large events and gatherings are held. Be prepared if someone gets sick during or after the event. It remains important to continue to wear a mask, maintain physical distancing, practice hand hygiene, and respiratory etiquette, and stay home when appropriate.

How You Can Help

How can you help those impacted in India and other countries experiencing a surge in COVID-19 infections? There are large international aid groups that are providing resources to India, but also smaller community groups that are working on providing medical supplies, PPE, and food to families who have been affected by lockdowns.

A list of organizations can be found here.

Vaccine Update

Nearly 150 million Americans have received the first dose of vaccine (44% of the US population) and almost 100 million (29%) have been fully vaccinated against the coronavirus that causes COVID-19. Of those over 65 years of age, 66% are fully vaccinated but the percentages decrease with each younger decade. The percentages of vaccinations by race and ethnicity are difficult to interpret because of missing data but the message is simple: every adult should receive a vaccine!

Understanding VITT

You may be hesitant to get vaccinated because of the recent reports of blood clots occurring after the first dose of the AstraZeneca vaccine (ChAdOx1 nCoV-19). This vaccine is produced using a recombinant chimpanzee adenoviral (not adenoviral associated or AAV) vector encoding the spike glycoprotein of SARS-CoV-2. Recently, three separate publications described 39 people with a newly described syndrome characterized by blood clots, primarily cerebral venous sinus thrombosis (a specific type of stroke) and low platelet counts (thrombocytopenia) that developed 5 to 24 days after initial vaccination. Most of the patients included in these reports were women younger than 50 years of age, some of whom were receiving estrogen-replacement therapy or oral contraceptives but only a few were known to have had previous blood clot (thrombosis) or a preexisting condition leading to the tendency to form blood clots. The medical community of clinicians and scientists quickly worked to understand how to manage these people and ascertain what the underlying cause for the blood clots and low platelet counts were. Surprisingly, it was uncovered that this is likely due to an “autoimmune” heparin-induced thrombocytopenia like condition in which the vaccine recipients formed antibodies against a platelet protein, platelet factor-4, which resulted in the what is now called vaccine-induced immune thrombotic thrombocytopenia (VITT). We do not understand everything about this problem, but scientists continue to work on it. The incidence of VITT is estimated to be about 1 case per 100,000 ChAdOx1 nCoV-19 vaccines administered but must be considered in the context of the underlying incidence of cerebral venous sinus thrombosis in the general population (estimated at 0.22 to 1.57 cases per 100,000 per year). Notwithstanding the severity of these incidents of blood clots, the relative benefits of preventing COVID-19 disease, a condition with a death rate of 1 to 2%, and the potential risk of long-term complications must be weighed against the risks of vaccination. The message again is simple, every person who is eligible should receive a vaccine!

Finally, I would like to take a minute and appraise you of the important initiative that NHF (https://www.hemophilia.org/research) along with the American Thrombosis and Hemostasis Network (ATHN, www.athn.org) is undertaking to address the important gaps in care that our community has identified. It’s true we have made amazing progress in the past decade, but many important scientific questions remain to be answered to build on the improvements in patient-outcomes we have witnessed. This effort strives to accelerate progress in several areas identified by individuals with bleeding disorders, their families, and their clinicians. We recently announced our plans for the NHF’s State of the Science Research Summit, to be convened in September 2021. We aim to bring together not only experts in bleeding disorders but also those across a wide range of disciplines in complementary fields, representing the views of the entire community. With these rich and diverse perspectives, we can better dissect these issues and determine how we can make meaningful progress. Working groups will come to the Summit with ideas on these six themes:

• In Hemophilia A and B … How can we use new advanced technologies to improve diagnosis and discover therapies that make life with hemophilia more manageable?
• In von Willebrand disease, blood vessel disorders, and platelet disorders… What is needed to introduce more targeted and accessible diagnostics and therapies for people with these disorders?
• For those with ultra-rare bleeding disorders … How can we better understand the biology of these rare conditions and what do we need to know to improve diagnosis and treatment?
• For women and girls with inherited bleeding disorders … How can we encourage more focus on the needs of this population, such as non-invasive prenatal testing or therapies for bleeding in the reproductive system?
• To encourage research momentum … How can we support and encourage more trainees of all disciplines to join the hematology professional community? How can we build our funding sources and foster a research culture at all levels to sustain important research for patient care?
• And to support health equity …. Where can we make the greatest impact toward more equitable and more inclusive access to care? What digital health tools can be implemented in this community

I understand that these are challenging topics, but by working together, we can identify and advance discovery efforts potentially creating transformational impact for the next generation of care.