CME INDIA Presentation by Admin.

India soon goes for vaccination. Many of us are excited. It is expected to bring needed herd immunity and abatement of all restrictions we are seriously tired of. At this juncture, what are the questions in your mind?

“I’m not tired of challenges. I’m tired of people challenging me for nothing”  – Ces Peta

CME INDIA Discussion

Dr A K Virmani, Diabetologist, Jamshedpur:

• I wonder why people are so excited about the vaccines.
• Of course, there are a wonderful step ahead but the way they have undergone phase 1-3 trials in such a short period leaves a lot to be desired about their efficacy, safety and immunity for how long (?)
• Nobody knows the facts and everyone is fishing in (troubled) waters
• The only thing that one is definitely sure of is that even after two doses of vaccine the masks, social distancing and hygiene SHOULD be continued.
• Looking at the present situation I’m sure hardly anyone will follow it

Dr Meena Chhabra, Diabetologist Delhi:

• Efficacy does not need a study for 5 years. Immunity if it disappears one can revaccinate.
• Short term morbidity and mortality of COVID-19 very high. Obviously, we are excited about the vaccine. I will get on day one!!
• Seen too many patients die seen friends and neighbours die have two friends who have developed pulmonary fibrosis another one is in ICU with psychosis as she saw so many deaths.
• I am motivating all my patients that whenever offered please take the vaccine.

Dr N K Singh:

• Are you going to take or not?

Dr Anil Kumar, Consultant Psychiatrist, Ranchi:

• First day first show

Dr Ambrish Mithal, DM Endo., Delhi:

• I am very positive about the vaccines. At least they will offer SOME protection.
• This does not mean that we will give up precautions. But at least there is some hope.
• It’s a remarkable feat of science to develop them so fast. Like with corona, we will only get some answers with time. Maybe we need another one in 6 months.
• I have lost several friends and patients in this pandemic. I will not wait for herd immunity – if it ever happens. I will get the vaccine the day I am allowed to/entitled to !!☺️

Dr Awadhesh K Singh, DM Endo., Kolkata:

• Completely agree. Can’t be better explained than this 👏🏻👏🏻💐🙏🏽

Dr Anil Motta, Sr Con Max Hospital, Delhi: FULLY ENDORSED SIR 👍

Dr Arvinda J, Bengaluru: Well and very aptly said.

Dr Supriyo Mukherjee, Diabetologist Physician, Samstipur:

• Very true.

Dr Shashank Joshi, DM Endo., Mumbai:

• Vaccines clearly are needed as long as they are safe and they will clearly take the sting out of the fatalities of the dreaded unpredictable virus
• I agree with Dr Ambrish.

Dr Ambrish Mithal, DM Endo, Delhi:

• Severity of infection will come down at least. If it becomes like a usual viral that’s also acceptable.

Dr Rajneesh Tyagi Physician, Noida, UP:

• Is it mandatory for everyone?? That should be the criteria for an ideal vaccine sir. Isn’t it? But I don’t think we have enough data and importantly time to call it ideal yet.

Dr Shashank Joshi DM Endo, Mumbai:

• No, it’s voluntary.

Dr Umesh Khan, Chairman API, Jharkhand, Jamshedpur:

• Ideally it should be. Because if one does not take vaccine, he will, if get infected, from any source, will spread the infection.
• We should encourage our pts and contacts to take it to prevent the spread as much as possible.

Dr D P Khaitan, Gaya:

• Vaccine is the immediate answer and Herd immunity is somewhat delayed journey.

 Dr Narsingh Verma, Lucknow:

• I have reservations about success of vaccine. Perfect answer is our immunity only.

Dr Ravi Kirti, Hod Med AIIMS, Patna:

• Another word for vaccination is immunisation.

Pearls from Editorial in JAPI

COVID-19 Immunity to Vaccination in India by Dr Shashank R Joshi, Dean, Indian College of Physicians, Mumbai, Maharashtra; Joshi Clinic, Lilavati Hospital and Bhatia Hospital, Mumbai, Maharashtra

• Research has been the cornerstone of the development of modern medicine and the ultra rapid super pace at which COVID vaccines are being developed is another milestone for us.
• Virulence, host immune response and COVID-19 risk score2 and vulnerable groups need to be kept in mind in the global and Indian plan of covid-19 immunisation which is in its infancy now.
• In 2021, we are now past more than a year after discovery of COVID-19 and its microbe the RNA SARS CoV2 virus will Vaccinating Adults Be Enough to Curb Spread of the Virus?
• Essentially nothing can replace aggressive “masking”, distancing with sanitation apart from avoiding crowded clusters and poorly ventilated spaces.
• Independent of COVID-19 appropriate behaviour the big question is does exposure to SARS Cov2 confer some degree of protection from COVID-19 reinfection?
• Herd Immunity is still elusive but still plausible and we are all looking at Vaccines now.
• m RNA platform vaccines (Pfizer, Moderna etc) are essentially researched on in USA, UK and Europe and have obtained Emergency Use authorisation (EUA) by the US FDA but are unlikely to be available for India in near future. They offer up to 95 % protection, but side effects are yet not fully known.
• The third vaccine in India is being made by Serum Institute with Astra and Oxford university which is leading the race because it’s likely to get EUA in UK and has conducted trails in UK, South Africa, Brazil and USA.4 In India it undergoing a special phase 2/3 trial under drug controller’s supervision. This vaccine uses a “Spike protein “and the vector is a chimp adenovector. It’s does not have the challenges of very low temperature storage and transportation. However, it has two issues one is the dose to effect co relation had an issue and second safety. Both will hopefully be dealt with very well by the group. The dose in UK showed better efficacy with lower dose compared to higher dose but this will be sorted out soon by the innovator. The safety pauses of some side effects have now been cleared by the British regulators. Indian regulators will look at both global and India data and may give a fast-track emergency approval for the same.
• The British new variant, referred to as SARS-CoV-2 VUI 202012/01 (Variant Under Investigation, year 2020, month 12, variant 01), shows an estimated potential to increase the reproductive number (R0) by ≥0.4, with an estimated increased transmissibility of up to 70%, according to the report. There is no indication, as of now, of increased infection severity associated with the new variant
• Currently, the clinical significance of these antigenic drifts is unknown. Other than potential higher transmissibility, early indicators don’t allow us to predict if it will be more virulent or will lead to a severe outcome. Also, currently it appears to be unlikely to impact the ongoing vaccine programs, though it may get incorporated in the future.

(Journal of The Association of Physicians of India ■ Vol. 69 ■ January 2021)

CME INDIA Learning Points

• At this desperate time, available evidences are weak regarding safety and efficacy of COVID vaccines.
• COVID appropriate behaviour is needed after vaccination but after vaccination people are likely to bypass it due to human psychological factors.
• Vaccination is not mandatory.
• In spite of all pitfalls, COVID vaccine is the need of time and it must be encouraged.
• Crucial to success of any COVID Vaccine: Trust it, have Confidence in it.

CME INDIA Tail Piece

Now time to know few facts about Anaphylaxis due to the Vaccine.

It can happen rarely, but we must be ready to tackle it. NEED OF THE HOUR. Any commercial tests available?

Source: CDC

The two commercially available lab tests are:

• Tryptase (a mast cell marker) and SC5b-9 (terminal complement complex)
• Tryptase is released from mast cells during anaphylaxis. SC5b-9 (terminal complement complex) is a measurement of complement system activation.
• These lab tests can be transiently elevated shortly after a severe allergic reaction.  The ideal time window to collect blood for these two tests is between 30 minutes and 90 minutes after the reaction began.
• However, these blood tests might still remain elevated up to 6 hours after the reaction began. Collecting blood earlier than 30 minutes after the reaction began could yield results that would be more difficult to interpret.

Management of anaphylaxis at a COVID-19 vaccination site

• Rapidly assess airway, breathing, circulation, and mentation (mental activity).
• Call for emergency medical services.
• Place the patient in a supine position (face up), with feet elevated, unless upper airway obstruction is present or the patient is vomiting.
• Epinephrine (1 mg/ml aqueous solution [1:1000 dilution]) is the first-line treatment for anaphylaxis and should be administered immediately.
  • In adults, administer a 0.3 mg intramuscular dose using a premeasured or prefilled syringe, or an autoinjector in the mid-outer thigh.
  • The maximum adult dose is 0.5 mg per dose.
  • Epinephrine dose may be repeated every 5-15 minutes (or earlier) as needed to control symptoms while waiting for emergency medical services.
  • Because of the acute, life-threatening nature of anaphylaxis, there are no contraindications to epinephrine administration.
• Antihistamines (e.g., H1 or H2 antihistamines) and bronchodilators do not treat airway obstruction or hypotension, and thus are not first-line treatments for anaphylaxis.
• However, they can help provide relief for hives and itching (antihistamines) or symptoms of respiratory distress (bronchodilators) but should only be administered after epinephrine in a patient with anaphylaxis.
• Because anaphylaxis may recur after patients begin to recover, monitoring in a medical facility for several hours is advised, even after complete resolution of symptoms and signs.

Recognise the Anaphylaxis EARLY

• Because anaphylaxis requires immediate treatment, diagnosis is primarily made based on recognition of clinical signs and symptoms, including:
  1. Respiratory: sensation of throat closing, stridor (high-pitched sound while breathing), shortness of breath, wheeze, cough.
  2. Gastrointestinal: nausea, vomiting, diarrhea, abdominal pain.
  3. Cardiovascular: dizziness, fainting, tachycardia (abnormally fast heart rate), hypotension (abnormally low blood pressure).
  4. Skin/mucosal: generalized hives, itching, or swelling of lips, face, throat.
• Early signs of anaphylaxis can resemble a mild allergic reaction, and it is often difficult to predict whether initial, mild symptoms will progress to become an anaphylactic reaction. In addition, not all symptoms listed above are necessarily present during anaphylaxis, and not all patients have skin reactions.
• Symptoms are considered generalized if there are generalized hives and/or more than one body system is involved.
• If a patient develops itching and swelling confined to the injection site, the patient should be observed closely for the development of generalized symptoms (beyond the recommended observation periods noted above, if necessary).
• If symptoms are generalized, epinephrine should be administered as soon as possible and emergency medical services should be sought.

Disclaimer

1. Please be alert that discussions in this article is based on general perception and available scientific sources.
2. To avoid confusion it is to be appreciated that everyone can have an opinion, which may not be scientifically correct. Such discussions help us to peep into right direction to some extent.

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