Autoimmunity & the COVID Vaccine

While I have enjoyed my 14-month vacation, I’m ready to start socializing again. And while I grieve for the businesses that have failed and the people who lost their jobs, as well as my son and all the other athletes/thespians/etc. who lost their senior year, I have loved getting to stay home instead of having to always be on the go. It’s been peaceful and relaxing, and I haven’t had to dream up excuses to get out of invitations. Since February 2020, aside from taking my youngest to college, the only places I have been are to doctor appointments and the grocery store. I did not have my family over for Thanksgiving or Christmas, and my mom’s 80th birthday party was virtual. I have not been to church in over a year. My weekly knitting group has continued to meet, but I have not attended. I don’t even have to drive to every doctor’s appointment, which saves me about two hours per visit thanks to virtual medicine! I love getting to stay home, but I don’t want to have to stay home. IF the vaccine is safe and effective (that’s a big if), people could start meeting together again. I might like to do that once in a while.

But do the benefits of this vaccine outweigh the risks? Never have any vaccines (even MMR) seemed so controversial as the COVID vaccines. We see people thrilled that a vaccine is finally available and who signed up as soon as they possibly could. We see others who vow they will never get the vaccine, no matter what. And there are people in the middle, who support the idea of a vaccine, but have questions and concerns about what’s currently available.

Full disclosure, I am in favor of vaccines (see Vaccines, Vaccine Safety, Is the Polio Vaccine Safe?, and Why I Got the H1N1 Vaccine). I have friends who are anti-vaxers and friends who are not. I have family members who believe they had C19 in the first wave, January 2020. I have family members who are in medical and nursing school so who have been able to provide different perspectives and better information than the media. I have friends and family members who have been vaccinated already, and I have friends and family members who say they will never be vaccinated. I’ve heard a lot of arguments on various sides of this issue.

Yesterday my family physician’s office phoned to recommend that I make an appointment for the vaccine. And I just don’t know. I support the idea of a vaccine. I’m just not convinced that the COVID vaccines are appropriate at this point.

  • Vaccines might not work for people who are immunocompromised. A study recently published in JAMA looked at a subset of immunocompromised patients – specifically, 436 transplant recipients – and tested for antibodies to see if the vaccine actually worked. Only 17% of patients developed antibodies, which doesn’t give me much hope that the vaccine is effective. It’s significant to note that of the 76 people who did develop antibodies, 69% had the Moderna vaccine and 31% had the Pfizer-BioNTech vaccine – we’re not told whether the full group of 436 had equal numbers of people receive the two different vaccines (and this was done before J&J’s vaccine was available so there is no data at all on that one). This was transplant recipients, not people with RA, so we don’t know if the same thing would apply to others. My doctor was not aware of this study and was going to do some research and then get back to me. They said that they’d call today, but I still haven’t heard anything.
  • At Washington University in St. Louis, they are doing a study that would be more applicable to people with RA, but those results are not available yet. Since results were estimated to be available in late February or early March, I’m curious why those results have not been released. Either the results support vaccination or they don’t. If they do, you’d think results would be published in an effort to persuade people.
  • There is no safety data yet. When they come out with a new flu vaccine every year, they use the same technology and just swap out the specific strain – so even though it’s a “new” vaccine, we have safety data from prior years and can trust that the vaccine is relatively safe. At least, that’s what we’re told. That’s not what they did with this vaccine. The companies that developed a COVID vaccine used entirely new technology. While manipulating RNA might be an exciting concept in the laboratory, we don’t generally use the world-wide public as a series of petri dishes; we have small-scale clinical trials first to establish efficacy and safety, then expand to get more data. That wasn’t done, and while I understand the definition of emergency, it hasn’t been demonstrated that an unproven vaccine is the most appropriate response to said emergency. In the past, some drugs and vaccines which went through a rigorous approval process were later pulled from the market due to safety concerns (for instance, in 1976, the swine flu vaccine caused an increased chance of GBS; in 1998, the rotavirus vaccine caused bowel obstructions in some infants). COVID vaccines haven’t even been through that rigorous process; they got emergency approval. We have no way of knowing twenty years down the road if it will turn out the vaccine was really safe. We don’t even have two-year data. I have no problem with people who are willing to be guinea pigs; my problem is with making the vaccine mandatory (which apparently some employers are talking of doing). Nobody should be compelled to get any vaccine until the safety data is conclusive.
  • We have no recourse if things go wrong. With some vaccines in the United States, people who can prove they were harmed by a vaccine can file a claim with the National Vaccine Injury Compensation Program. First, VICP keeps changing the rules to that program to disqualify the most common injuries, which means that people who are injured are often SOL. More pertinent to this discussion is the fact that the COVID vaccine doesn’t qualify for VICP. Instead, COVID would theoretically fall under the Countermeasures Injury Compensation Program. It appears that the goal of this program is to avoid paying claims, not to help people. To date, zero COVID claims have been pain. None. Nearly 2,000 of the people who received the COVID vaccine suddenly dropped dead within three days, yet all were ruled completely unrelated to the vaccine. And while I understand that there are those who will always try to take advantage and will file a claim in hopes of getting a windfall, I also have trouble believing that people who were already at death’s door bothered to go get vaccinated. The government has created a situation where people don’t trust that we’re being told the truth. Think about the GSWs that were counted as COVID deaths – just as they lied to make the numbers look worse, they can just as easily lie to get out of paying claims. And I understand that things can go wrong when we get sick, but that is very different than being harmed by something that is supposed to help you.

Rheumatologists are told to talk with patients about getting vaccinated. ACR even published guidelines for that discussion. And I find it interesting that they acknowledge that lack of long-term safety data is a concern, they acknowledge that other conditions could be a factor, then rush right on to discuss how to coerce patients into getting vaccinated without ANY mention of how to address those concerns. Really? As a person who has had a bad reaction to a vaccine and who has numerous allergies including anaphylactic reaction to shrimp, I believe those concerns should be addressed instead of brushed aside. My mother had a long career in the medical field and ultimately had to retire early after developing a latex allergy; she’s understandably hesitant to be vaccinated. If someone has managed to make it over a year without getting sick, couldn’t the same precautions continue until we have a little more safety data on this brand new technology?

That’s just my thoughts. Part of me is tempted set aside all my misgivings and just make sure my will is updated so I can go get the shot. I’d prefer to see another year or two of safety data, but it would be nice to get back to seeing friends every once in a while.

International Foundation for Autoimmune & Inflammatory Arthritis has added a page to their website for answering questions that people might have about the vaccine. The slant there is pro-vaccine, not my I’m-just-not-sure. Go check it out.

Regardless of which way you choose, stay safe!

I Am Not Afraid

I am not afraid of being hit by a car.  That’s not to say that I would want it to happen; it’s just not something that I live in fear of.  Most of the time, I don’t even think about the possibility. Instead, when the situation warrants, I take precautions because I recognize that being hit by a car can be deadly.  Even when it’s not deadly, recovery from the injuries can be painful, time consuming, and expensive.  Therefore, I don’t play in the freeway. I look both ways before crossing the road.  Basically, I am careful to avoid situations that would increase the likelihood of my being hit by a car.

And I am not afraid of being infected with SARS-CoV-2 and contracting Covid-19, but it’s not something I would particularly want to happen any more than I want to be hit by a car.  I recognize that the disease can be deadly, and even when it’s not, recovery can be painful, time consuming, and expensive.  So I take reasonable precautions.  Basically, I am careful to avoid situations that would increase the likelihood of my being hit by disease.

There are times that it might be safe to play in the road.  For instance, when I was young, we lived on a cul de sac.  It was common for all the neighborhood kids to play in the road – running races, playing tag, kick-the-can, red-rover…  While playing, we all kept a look out; if a car turned onto our road, everyone shouted “CAR” and dashed into the nearest yard.  That was long ago.  I no longer live on a cul de sac.  Where I live now, the speed limit is 50 and nobody drives that slowly.  It would be foolish for kids to play in the road here.  Circumstances can affect what’s safe and what isn’t.  Cul de sac – maybe safe.  Major thoroughfare? Not so much.

Likewise, in disease prevention, circumstances can affect what’s safe behavior and what isn’t.  People who are young and healthy, eat a perfectly nutritious diet, and have a robust immune system might feel comfortable in groups of germy people – just like I was comfortable playing in the road as a child.  However, there are people who have health considerations that make it a bad idea to engage in risky behavior.

And guess what?  You don’t know just by looking at someone what their circumstances are.  That person who is staying home instead of getting together with friends?  Maybe that person has asthma.  Or diabetes.  Or has another health condition that means always taking extra precautions to avoid germs.  People should not need to divulge their medical history to others to avoid ridicule, and should not have to justify why they are taking steps to stay healthy – steps, by the way, that they may well have discussed with their team of physicians long before the events of 2020 ever hit.  Other circumstances are at play, too.  In some industries, if an employee gets sick, the county can shut down the business for a month.  One sick individual can put hundreds out of work.  It’s prudent for people to be cautious in their interactions and avoid those who are not careful about avoiding germs.

This year, I am having a peaceful Thanksgiving at home.  For the first time in over thirty years, nobody is invited to join us.  I will not be sad nor alone. I’ll be thankful for family who understand. Some of the folks who might have come have been gathering in groups, eating at restaurants, and choosing to live as if China did not let loose yet another disease on our world.  That is their prerogative.  For myself, I am choosing not to play in the freeway.  That doesn’t make me fearful.  It makes me prudent.

Vitamin D – Sources & Amounts

Technology is great.  A couple taps on my phone lets me confirm medical appointments, check test results, or even communicate with my doctor.  It seems incredibly efficient for my doctor to be able to make notes when reviewing lab results and not have to task someone to make phone calls.  Just like that, I saw the note:

RECOMMEND ADDING EXTRA 1000 IU OF VITAMIN D TO DAILY REGIMEN

Since I could see the lab’s numbers, that recommendation wasn’t really a surprise.  Vitamin D might be easy to get in the tropics, but deficiency is pretty common in the rainy Pacific Northwest since the best way to get Vitamin D is from sun exposure and we don’t have a lot of sunshine.  So how do we get Vitamin D?  And how much do we need?

Vitamin D is primarily synthesized in our bodies based on exposure to sunlight. Think of it like photosynthesis for people (thankfully we don’t turn green!). Both the liver and the kidneys play a part. But if we’re missing the initial sunshine step, it’s pretty difficult for the kidneys and liver to do their part. Although it’s theoretically possible to get Vitamin D through our diet (our liver & kidneys do the same hydroxylations whether our Vitamin D is acquired through diet or sunshine), there aren’t that many dietary sources.  Foods containing vitamin D include fish, eggs, UV mushrooms, and pork. That’s a pretty short list.  I’m not counting fortified products, since the whole point is to find nutrient-dense foods instead of taking supplements.  Hiding supplements in the food doesn’t change the fact that they’re supplements instead of naturally-occurring.  Plus the fact that the foods they add Vitamin D to are mainly dairy products, ensuring that people who don’t get calcium from dairy also don’t get Vitamin D.  But if you consume dairy products, you can add that as a Vitamin D source, too.

So What Does Vitamin D Do for Us?

Vitamin D does more than just prevent rickets in growing kids. It reduces inflammation (!), modulates cell growth, helps us metabolize glucose, affects immune function, and helps build strong teeth. 

A major job of Vitamin D is to help us absorb calcium.  We can take all the calcium pills we want, but if we’re not getting enough Vitamin D, the calcium is not going to do much good – and our meds can affect things further. For instance, prednisone interferes with Vitamin D. Everyone taking DMARDs is at increased risk for osteoporosis, so metabolizing calcium is extremely important, which means that Vitamin D is important.  People taking Disease Modifying Anti-Rheumatic Drugs need to be particularly careful to get enough Vitamin D so that their calcium is properly absorbed or they could end up with soft bones.  Who needs more problems?

But there’s more.  There is a clear link between MS and low 25(OH)D levels. Will future studies show a link to other conditions?  Studies are still underway because data from previous studies is unclear. There could be a link between low Vitamin D and cardiovascular disease (which is already a risk for people with autoimmune diseases).  The data on the link between Vitamin D and cancer is conflicted, but it appears that both too little and too much might increase the risk of cancer, and that Goldilocks-right-in-the-middle amounts might decrease mortality in people who get cancer despite having good Vitamin D levels. There are also studies on a link between low Vitamin D and type 2 diabetes.  Another study seems to indicate that overweight people can increase their Vitamin D levels by losing weight, the thinking being along the lines of D getting trapped in the outer fat cells – losing that fat then makes the D available to metabolize.  It’s fascinating.

Do We Really Need 15 mcg Per Day?

There is a tidy little chart listing US Recommended Dietary Allowances that says everyone should consume 15 mcg a day until age 70, when it goes up to 20 mcg.  But then there’s the fine print.  That’s dietary Vitamin D assuming minimal sun exposure. Those getting plenty of sunshine on their skin wouldn’t need as much Vitamin D from their food. 

On the other hand, not everyone agrees with the US RDAs.  Only 10 mcg are recommended in the UK.

Labs Can Measure Blood Serum Vitamin D

The amount of dietary Vitamin D we take in doesn’t correspond directly to the amount in our bloodstream.  Doctors can order a lab test to check our levels. The reliability of that test is questionable, but we work with what we have and use the Food & Nutrition Board’s definitions of appropriate levels of Vitamin D. I note that the lab I use has slightly different definitions:

Before we get too dogmatic about those number being etched in stone, we need to recognize that the NIH fact sheet on Vitamin D tells us,

“Optimal serum concentrations of 25(OH)D for bone and general health have not been established because they are likely to vary by stage of life, by race and ethnicity, and with each physiological measure used. In addition, although 25(OH)D levels rise in response to increased vitamin D intake, the relationship is nonlinear. The amount of increase varies, for example, by baseline serum levels and duration of supplementation.”

Basically they’re saying that nobody knows for sure how much Vitamin D we truly need, but they’ve taken as good a guess as they can.

Then there’s the Endocrine Society, which says that people should get as much Vitamin D as it takes to keep their serum 25(OH)D levels above 75 nmol/L (30 ng/mL).  That’s quite a bit higher than the Food & Nutrition Board’s recommendation that 50 is adequate.

Putting everyone’s guesses together, I take it to mean that ideal serum levels would be in the 75-96 range, and we need to figure out a safe way to get our Vitamin D to that level.

But we have to be careful. As with other fat-soluble vitamins, toxicity is a real possibility. Current theory tells us that 1,000 IU daily can raise the serum level by 10 ng/mL, so that much supplementation should theoretically be safe for people whose numbers are low.  The Tolerable Upper Limit for adults is 4,000 IU, so 1,000 should be perfectly safe.  Don’t take too much, though.  Toxicity sounds not just unpleasant, but dangerous: nausea, vomiting, pain, dehydration, kidney stones, renal failure, heart problems, or death.

Note that those scary results of toxicity are thought to be from supplements. Getting Vitamin D from sunshine and food is considered safe.

Which foods contain Vitamin D?

Six ounces of salmon or swordfish contain 142% of the daily Vitamin D we need.  An equal amount of halibut provides 50% of our day’s Vitamin D.  A three-ounce can of tuna provides 9%. 

Supposedly a 1-cup serving of crimini mushrooms has zero vitamin D, unless they’ve been treated with UV light, in which case they provide 122% of our daily Vitamin D.  This is most peculiar. I’m not sure if it means we should be setting our mushrooms out in the sunshine before consuming them, or what the deal is, but if I had sunshine, I could set myself in it instead of my mushrooms. 

Basically, unless you’re eating a ton of salmon every day or drinking milk, it’s nearly possible to get enough Vitamin D without taking supplements or going out in the sun.

How Much Sunshine Do We Need?

We don’t need as much sunlight as you might think. Up to one hour three times a week should be sufficient. Note that since Vitamin D is fat soluble, extra is stored (as opposed to water-soluble vitamins that are excreted if we get more than we need).  It appears that we can spend time in the sun every-other-day, not daily.

How long we should spend in the sun depends both on how dark our skin is and on how intense the sunlight is.  We just need to know the UV index – and I’ve discovered that my smart watch can provide that information. It’s also possible to check the weather forecast for the UV Index.

It’s not enough to look out the window to see if it’s sunny or not. UV index depends on other factors, including angle of the sun (ie time of day and season of the year). For instance, it’s a beautiful day here, but the sun is so low that despite the blue sky, the UV index is only 2.

Once I know the current UV index, GB Healthwatch has a handy table for looking up how much time is needed in the sun (while wearing shorts and a t-shirt). Unfortunately, they don’t document where the data came from. Nonetheless, it’s a starting point.

Conclusion

The average person needs 15 mcg of dietary Vitamin D, every day, or needs to spend up to an hour getting sunlight directly on the skin (directly, not through a window). The farther from the equator people live, the less likely they are to get adequate Vitamin D from the sun, so supplements might be needed. It’s also possible (but fairly expensive) to use a special UVB light or spend time in a tanning bed.

People with autoimmune diseases need to be especially vigilant in getting enough Vitamin D, both to help control inflammation, and to reduce the probabilities of complications such as cardiovascular disease and osteoporosis.

Wishing you well!

***** ****** ******

1 Food & Nutrition Board
2 National Academies of Sciences, Engineering, and Medicine

Resources:

*Vitamin D Fact Sheet for Health Professionals

*Vitamin D: A Rapid Review

*Get Vitamin D from Sun Exposure

*Top Ten Vitamin D Foods