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Even if not hospitalized, COVID-19 often produces the most severe infection individuals will experience in their lifetimes and can produce lasting symptoms of fatigue, weakness, brain fog and cardiovascular damage.
This week’s meeting of the Center for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) focused on approval of the Pfizer/BioNTech vaccine boosters. I was keenly interested in this meeting. For me it was personal. For almost 2 years I have written articles for Infection Control Today®, I have also developed a significant medical issue. This was diagnosed during the pandemic and is a testament to not putting off medical evaluations because of the virus. Initially, I chose to follow conservatively, but because of progression, I elected to have surgery. Surgery that was cancelled because of filled medical centers due to a near collapse of our health care system from unvaccinated COVID-19 patients filling Kentucky and Tennessee hospitals. In addition, there is also a critical shortage of health care personnel.
Thus, I am very biased, and watched with horror as the committee declined to approve boosters for our frontline workers, including health care personnel. This happened even after CDC Director Rochelle Walensky, MD, advised the committee to not be swayed by influences other than science. It did not appear the committee heeded this advice. Instead, it appeared to fall prey to political talking points and what I feel was sub-par research to bolster its position.
At the beginning of the meeting there was time for public comment, and I gave a 3-minute commentary stressing the importance of having to act now and that the United States does not have the luxury of waiting for randomized clinical trials. Non-action is also an action. I stressed the importance of long COVID-19 and pointed out even those with mild or moderate infections were at risk. I advocated for the expansion of the Food and Drug Administration’s recommendations for boosters for those at high risk of occupational SARS-CoV-2 exposure. And finally, that the degree of exposure should not be a consideration, since being exposed is like being pregnant: You either are exposed, or you are not.
A major political talking point, which many committee members appeared to have fallen for, is that if you are not hospitalized you are fine, and prevention of COVID-19 not requiring hospitalization is not a priority. Many refer to this as “mild” or “moderate” disease. Throughout the FDA and CDC approval process I heard that the goal which they were trying to accomplish was to keep patients out of the hospital and ICU. I do not know who set this goal. Certainly not the White House. Their goal appears to be the prevention of morbidity and mortality along with keeping the supply chain open by protecting frontline workers. Already in Kentucky we are seeing signs of collapse with our schools having difficulty in obtaining food supplies for student meals.
The problem with this is that hospitalizations and severe infections are often based upon a patient’s pulmonary symptoms and SARS-CoV-2 is not like the flu, it affects almost every organ of the body. Patients may not have a primary pulmonary presentation, some may have primarily gastrointestinal, cardiovascular or central nervous system symptoms. Cardiovascular involvement is common and can occur in those with no or mild symptoms. Myocarditis often is asymptomatic. Thus, the virus damages many organs of the body, resulting in long COVID-19 which afflicts 10% to 30% of patients with mild to moderate symptoms.
In other words, even if not hospitalized, COVID-19 often produces the most severe infection individuals will experience in their lifetimes and can produce lasting symptoms of fatigue, weakness, brain fog and cardiovascular damage. It is unbelievable to me how the loss of smell is just shrugged off as a minor symptom. As a retired ear, nose, and throat doctor, if I would have performed a surgery which resulted in the loss of smell I could have been sued for hundreds of thousands of dollars.
Another political talking point is the assertion that health care workers have been provided adequate protection and are not at high occupational risk for SARS-CoV-2 acquisition. We heard this assertion during the committee meeting. In addition, it was stated there was research to support this position.
However, the main research I could find is one published by Jacobs, et al. in JAMA Network Open which compared the seropositivity in health care workers with the general community.(4) As pointed out by a commentator, Lisa Brosseau, ScD, one of the overriding problems of this study is that the conclusion that “these findings provide reassurance that current infection prevention practices in diverse health care settings are effective in preventing transmission of SARS-CoV-2 from patients to HCP.” Is not supported by the data. In addition, Brosseau points out that “the investigators fail to note that health care personnel had an overall infection incidence rate of 440/10,000 (4.4%), 6 times higher than the average community infection rate of 72.4/10,000 (0.7%)” And that “a recent study found SARS-CoV-2 transmission between asymptomatic patients and health care personnel despite the use of medical masks and eye protection. It is time to stop pointing fingers at community transmission and recognize and address the importance of work-related exposure.” Finally, this study used serology and not PCR testing of actual infections. The health care worker participants volunteered for serology testing. I feel the control group needed better description to rule out any biases which may have been present due to differences in these 2 groups.
With the high viral load that health care workers are exposed to, along with the many reports I am hearing of breakthrough infections in these workers, they definitely need to be prioritized for boosters. Health care workers were among the first to be vaccinated and, thus, would be expected to be among the first to have waning vaccine immunity.
Even if community exposure was true, as stated by Helen Keipp Talbot, MD, of Vanderbilt University, who also voted yes, “…vaccinating health care workers, who are being exposed in the community, would help to maintain staffing levels at already overwhelmed hospitals.”
This is an argument which I wholeheartedly support, since I would not want to have my treatment prevented again due to health care workers afflicted with COVID-19.
Walensky swiftly acted and in the evening reversed the committee’s decision. The following was added to the CDC recommendations for individuals eligible for boosters: “People aged 18-64 years who are at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting may receive a booster shot of Pfizer-BioNTech’s COVID-19 vaccine at least 6 months after their Pfizer-BioNTech primary series, based on their individual benefits and risks.”
I feel this was a very wise decision which demonstrated proactive action and the ability to separate political rhetoric from science. I feel APIC needs to have a paradigm shift in thinking. These are not normal times; we need swift decisions which will often have to be based upon experience and the preponderance of evidence. As stated by John F. Kennedy “There are risks and costs to action. But they are far less than the long-range risks of comfortable inaction.”