To my colleagues & trainees who have contacted me in distress over the past few days, I see you and hear you.
I don't post my thoughts about the Middle East because—even though I have studied its history tremendously over the years—I recognize that there are more than one truth.
I understand how you fear—as Jews or people sympathetic to the tragedy that Israelis are experiencing—expressing your views or trying to counter views that see only one side of a dispute that is much older than the state of Israel.
I also understand how uncomfortable you have been made to feel when colleagues or supervisors use their (mostly) professional platform to acknowledge the unquestionable and tragic suffering of Palestinians yet fail to acknowledge the suffering many Israelis are also experiencing.
I also understand that there are legitimate non-antisemitic criticisms of Israel. But when fighting breaks out in the Middle East, antisemitism breaks out most everywhere else, and it is hard for you to escape the reality that there's an element of antisemitism in all of this.
I also understand that freedom of speech is fundamental to our society, and feel fortunate that we are afforded it. But I know you don't feel safe expressing online or to people posting how or what you feel. Such is social media.
My points: 1. If you feel unseen and distressed by your need to hide your views, I see and hear you. As do others. If it is affecting your ability to function, reach out for help.
I may not be able to help you, but if you feel the need, reach out to me.
2. There are victims on all sides of this equation, and as healthcare people we should know that all lives are equally precious. I pray and weep for all parties involved, and I would hope everyone shares those same ideals.
3. If you are in a leadership position choose your words and actions carefully. Equity, diversity, and inclusion means that all people and viewpoints matter—including the ones that aren't necessarily the loudest. You may want to reflect on how to encourage rather than stifle #EDI
Reluctantly, I feel I need to clarify some issues around why AZ doesn't make sense for most of Canada right now.
When NACI evaluated—using the hard endpoint of deaths—the risk-benefit of AZ vs. no AZ, it used a lower incidence 1 per 100 000.
With this modeling, it makes clear sense to give AZ vs. waiting for age 50-69 in a moderate incidence setting, and for all ages in high incidence setting.
But what happens if the VITT rate is 1:26 000 or 3.85/100 000? You get this ...
This means that it is only a slam dunk (vs. no vaccine) for age 50+ in high incidence (30 cases/100K/day) settings, and 40+ in very high incidence (60 cases/100K/day) settings. Even if VITT incidence is 1:40 000 (or 2.5/100K/day), your expected VITT deaths/100K are 0.63-1.0.
It all hinges on the estimates of VITT. Yesterday @COVIDSciOntario posted a VITT brief covid19-sciencetable.ca/sciencebrief/v… that gave updated estimates of risk: 1:26 000 to 1:127 000 (as opposed to govt doc using 1:100-250K), and I believe ours is the most accurate estimate of risk of VITT.
If we use the revised numbers, the incidence of an ICU admission from AZ vaccine becomes anywhere from 1.27-3.85/100 000. Using existing risk-benefit analysis, it means that it never makes "statistical sense" to use an AZ vaccine where the COVID incidence is moderate (7.5/100K/d)
Highlights for remdesivir 1. Not recommended for patients not on oxygen 2. Not recommended for patients mechanically ventilated. 3. Recommended for patients on low-flow supplemental O2 4. Consider for patients in between low-flow O2 and MV
Much of our advice comes from insights around this table of 28d mortality and the studies involved. We recognize that this isn't straightforward guidance.
I will start off by saying what we know about systemic corticosteroids in patients with COVID:
They likely work and save lives if patients need supplemental O2 or supported ventilation. The strongest evidence comes from the massive RECOVERY trial (N=6435, nejm.org/doi/full/10.10…). Importantly, dexamethasone appeared potentially harmful for patients not requiring O2.
It's possible that the best decision for the population and the best decision for individuals are different.
In a young otherwise healthy person where other vaccines are available soon and they can mitigate their risk, the risk of illness/death from AZ > risk of death from COVID
Would a parent give their 12yo kid AZ if it were shown to be safe and efficacious in studies but still carried the VIPIT risk? I seriously doubt it. Then how about a 15yo? 20 yo? 21?
At some age benefit > risk. NACI decided that that inflection point is 55y. I agree with them.
However, to the general public, the value of getting as many people as possible vaccinated is huge.
The argument of being in a 3rd wave isn't being lost on me, but most of these vaccines during the 3rd wave will/should not go in young people.
1. Let us first be very clear—we are in a 3rd wave—and epidemiologically, we are somewhere comparable to early-mid December 2020. From @COVIDSciOntario@Billius27
2. A huge difference is ICU capacity. In mid-December, we had around 276 patients with COVID in ICUs, and around 181 on ventilators.
Right now, that number is 355 and 205, the ICU workers are tired, and those numbers are just starting to rise.
3. How quickly cases rise is unpredictable. If we're lucky the rise will be more like 🇫🇷 than 🇮🇹 or 🇦🇹 but it is very clear that truly steep growth often occurs and (if you follow the international press) it always feels like it is taking you by surprise. It ain't.