14-04-2021

WEDNESDAY, APRIl 14, 2021
5
Astra Zeneca vaccine and the question of blood clots
Benjamin Mueller
The AstraZeneca-Oxford vaccine has been deployed against
Covid-19 in at least 115 countries, some of them for several
months now. But it wasn't until a few cases of a rare bloodclotting
disorder - some fatal - emerged within the past
month or so that many European nations began to rethink its
use across all age groups.
Several of those countries, well stocked with alternate
vaccines, have now limited use of the AstraZeneca-Oxford
shot to older people, and a few have stopped using it
altogether. While the incidence of these clotting disorders is
extremely low, regulators and researchers are trying to raise
public awareness of certain symptoms - including headaches,
leg swelling and abdominal pain - especially in younger
people who have been vaccinated.
Public health experts, however, have expressed concern
that publicity surrounding the rare vaccine-related reactions
will fuel hesitancy, a particular problem in Europe. They
continue to emphasize that the AstraZeneca-Oxford vaccine's
benefits far outweigh the risks. In many nations, it is the only
vaccine available.
Below are some frequently asked questions.A blood clot is
a thickened, gelatinous blob of blood that can block
circulation. Clots form in response to injuries and can also be
caused by many illnesses, including cancer and genetic
disorders, certain drugs and prolonged sitting or bed rest.
Covid itself can trigger serious clotting problems. Clots that
form in the legs sometimes break off and travel to the lungs
or, rarely, to the brain, where they can be deadly.
The clots in recipients of the AstraZeneca-Oxford vaccine
have drawn heightened concern because of their unusual
constellation of symptoms: blockages in major veins, often
those that drain blood from the brain, combined with low
platelet counts. Platelets are a blood component involved in
clotting.
Researchers in Germany and Norway found that vaccine
recipients who developed the clotting disorder had produced
antibodies that activated their platelets and led to the clots.
The scientists suggested naming the unusual reaction
"vaccine-induced immune thrombotic thrombocytopenia,"
or VITT.
So far, researchers in Europe have not identified any
underlying medical condition among the vaccine recipients
who developed severe clotting issues that would help explain
their susceptibility.
Some health officials have said that younger people appear
to be at slightly higher risk from the clots. Because those
people are also less likely to develop severe Covid, regulators
said, any vaccine being given in that age group has to clear a
higher safety bar.
As of April 4, European regulators had received reports of
222 cases of the rare blood-clotting problem in Britain and
the 30-nation European Economic Area (the European
Union plus Iceland, Norway and Liechtenstein). They said
that about 34 million people had received the AstraZeneca
In rare cases, an immune reaction has led to antibodies that caused a serious clotting
disorder.
Photo: Reuters
vaccine in those countries, and that the clotting problems
were appearing at a rate of about one in 100,000 recipients.
European regulators said that as of March 22, they had
carried out detailed reviews of 86 cases, 18 of which had been
fatal.British health officials have described a somewhat lower
incidence of cases, perhaps as a result of having begun their
rollout of the vaccine in older people, who they say appear to
be less susceptible.
But they offered evidence this week that the risk of being
admitted to intensive care with Covid exceeded the dangers
of the blood clots in almost every scenario. The only group for
whom they said the risk of the clotting problems outstripped
that of coronavirus-related intensive care admissions was
people under 30 living in a place with low rates of Covid
cases.
People of all ages with a medium or high risk of exposure
to Covid were more likely to suffer serious health problems
from catching the virus than from being given the vaccine,
they said.
Germany, the Netherlands, the Philippines, Portugal and
Spain have recommended that the AstraZeneca vaccine be
given only to people over 60. Canada and France have
limited it to those over 55; Australia, over 50; and Belgium,
over 56. Britain, where the AstraZeneca vaccine was
developed, has been its staunchest defender, but announced
on Wednesday that it would begin offering alternative shots
to people under 30.
Denmark and Norway have stopped using the vaccine, and
the Democratic Republic of Congo delayed the start of its
inoculation program.Full vaccination with the AstraZeneca
vaccine requires two doses, but regulators in France have
recommended that people under 55 who have had one dose
get a different vaccine for their second shot. German health
officials have recommended the same for people under 60.
The AstraZeneca vaccine is not authorized for use in the
United States, but the company has said it would seek Food
and Drug Administration review.On Wednesday, the
European Medicines Agency said that the vaccine's labeling
should be revised to include the clotting disorder as a "very
rare" side effect of the vaccine.
In the United States, 300,000 to 600,000 people a year
develop blood clots in their lungs or in veins in the legs or
other parts of the body, according to the Centers for Disease
Control and Prevention. Based on that data, about 1,000 to
2,000 blood clots occur in the U.S. population every day.
With several million people a day now being vaccinated,
some of those clots will occur in those receiving the shots just
as part of the normal background rates, unrelated to the
vaccine.
In Britain, regulators have said, roughly one in 1,000
people are affected by a blood clot in a vein every year.But
medical experts said it was harder to discern the typical
background rate of the more unusual clotting cases being
observed in small numbers of recipients of the AstraZeneca-
Oxford vaccine. Cerebral venous thrombosis, or clotting in
the brain, has not always been well diagnosed, researchers
have said.
Still, German researchers have said those clots were
appearing more frequently in recipients of the AstraZeneca-
Oxford vaccine than would be expected in people who had
never received the shot.
European regulators had recommended that recipients of
the vaccine seek medical assistance for a number of possible
symptoms, including swelling in the leg, persistent
abdominal pain, severe and persistent headaches or blurred
vision, and tiny blood spots under the skin beyond the area
where the injection was given.
But that set of symptoms was so vague that almost
immediately, British emergency rooms experienced a surge
in patients who were worried that they fit the description. As
a result, some emergency room doctors have asked for more
central guidance about how to handle what they described as
largely unnecessary hospital visits.
German researchers have described specialized blood tests
that can be used to diagnose the disorder, and suggested
treatment with a blood product called intravenous immune
globulin, which is used to treat various immune disorders.
Drugs called anti-coagulants, or blood thinners, can also be
administered, but not a commonly used one - heparin -
because the vaccine-related condition is very similar to one
that occurs, rarely, in people given heparin.
Other vaccines, particularly the one given to children for
measles, mumps and rubella, have been linked to
temporarily lowered levels of platelets, a blood component
essential for clotting.
Lowered platelet levels have been reported in small
numbers of patients receiving the Moderna, Pfizer-BioNTech
and AstraZeneca vaccines. One recipient, a physician in
Florida, died from a brain hemorrhage when his platelet
levels could not be restored, and others have been
hospitalized. U.S. health officials have said that the cases are
being investigated, but they have not reported the findings of
those reviews and have yet to indicate that there is any link to
the vaccines.
Shortly after the safety concerns emerged last month,
surveys began to show that in Germany, France and Spain, a
majority of people doubted the safety of the AstraZeneca-
Oxford vaccine.
Use of the shot has suffered: Across Europe, 64 percent of
delivered doses of AstraZeneca's vaccine have been injected
into people's arms, markedly lower than the rates for other
shots.But European countries have been able to withstand
restricting use of the vaccine because they have purchased
shots from other makers, too.
The revival of social skills after a
year of isolation
Bonnie Tsui
As we move through the spring of The Great
Vaccination, many of us are feeling cautious
optimism, and also its flip side: creeping
dread.Maybe you have a sense of ambivalence
about how to interact with others again. If you
used to work in an office, you might be worried
about returning to work - but eager to see people
again. Or you find yourself having to confront a
neighbor about a longstanding problem - but
you're out of practice with conflict resolution. (I'm
not sure I remember how to talk to another
human anymore, let alone one I disagree with.)
Whatever the specifics, "there will be new forms
of social anxiety," said Dacher Keltner, a professor
of psychology and the director of the Social
Interaction Lab at the University of California,
Berkeley.
"People are really anxious about being out in
restaurants with friends, or about dancing with a
big sweaty group of people - or even about sharing
a yoga mat," he said. "It's always good to
remember individual differences - there's a lot of
variability. But there will be a lasting societal
legacy around intimacy, the noise that comes with
returning to school, the complexity of the
playground and of work."
Dr. Keltner has studied human behavior and the
biological and evolutionary underpinnings of
emotions for decades, with a focus on "pro-social"
states - behavior that strengthens connections
between individuals - that are especially good for
society. "We're hyper-social mammals - it's our
most signature strength," said Dr. Keltner, a cofounder
of the Greater Good Science Center who
was also a scientific consultant on emotions for the
Pixar film "Inside Out." "It's what sets us apart
from other primates: We help, we laugh, we
collaborate, we assist."
Lately, we've been living our lives siloed away
online, missing many of the essential face-to-face
experiences that are key to human interaction. It's
notable that Dr. Vivek Murthy, the newly
reappointed U.S. Surgeon General, has talked not
only about the physical and economic toll of the
pandemic, but also of "the social recession."
Before Covid, this kind of post-isolation anxiety
was most often suffered by people who re-enter
After a year of virtual gathering, getting back to real-life relationships can
be intimidating.
Photo: Eleni Kalorkoti
the civilian world after prison, wartime
deployment, humanitarian aid work or remote
expeditions. The challenge now is that so many
more of us will be experiencing some aspect of this
all at once, and coming back to social situations
with others who likely have their own fears too. It
is stalled social development, on a societal level.
Debra Kaysen, a clinical psychologist and a
professor of psychiatry and behavioral sciences at
Stanford University, said that coming back to socalled
"civilian life" can be disorienting, surreal
and difficult - and not just for combat veterans.
Her clinical and research work focuses on anxiety
disorders and trauma, and she has worked on
developing coping strategies for health care
workers dealing with mental health concerns
during the pandemic.
Now, everyone is trying to navigate conflicting
threat levels in a way that used to be specific to
those populations, she said. Cues that used to be
neutral or positive, like being around other
people (I love my friends and family!) are now
associated with threat (my friends and family
might infect me with Covid!). And we are
confronting the challenge of how to turn off that
alarm. "What's a true alarm and what's a false
alarm has gotten more confusing for all of us,"
Dr. Kaysen said.
So how do we relearn how to be together?Give
yourself permission to set small, achievable goals.
And accept that other people are going to have
different responses than you - the friend or family
member who wants to eat inside the restaurant
when you don't, for example, or who is ready to get
on a plane and take a vacation.
Accept that certain activities may feel tough for
awhile. Driving an hour to a meeting. Flying a redeye
to a conference. Attending a family reunion,
say, or four pandemic-postponed weddings in one
month.All of this can prompt you to ask, of your
family or your boss or even yourself: "Is it really
worth the time?" and "Now that I know things can
be different, do I want to go back to my old life?"
Recovering doesn't mean you go back to the way
you were before, Dr. Kaysen said, using kintsugi,
the Japanese technique of repairing broken
pottery with gold, as an analogy for coming out of
hard times with awareness of the change, and
stronger than before. "It's that you create a new
normal, one that's functional and beautiful - and
different."
Dr. Keltner agreed that we may need to "reeducate
ourselves" - "like, how do we hug again?"
Your timing might be off for a hug, or a joke or
even a compliment. "How do you look someone in
the eye so that it's not intrusive? How do you
compliment someone? You might not have done it
for a year."
Rather than be overwhelmed by everything at
once - for example, going to a party where you
have to adjust to greeting acquaintances, eating
with others and attempting to make small talk - all
at the same time - why not take things step by
step? This moment can be an opportunity.
Music therapy is increasingly used to help patients cope with stress and
promote healing.
Photo: John Smith
The healing power of music
Richard Schiffman
"Focus on the sound of the instrument,"
Andrew Rossetti, a licensed music therapist
and researcher said as he strummed
hypnotic chords on a Spanish-style classical
guitar. "Close your eyes. Think of a place
where you feel safe and comfortable."
Music therapy was the last thing that Julia
Justo, a graphic artist who immigrated to
New York from Argentina, expected when
she went to Mount Sinai Beth Israel Union
Square Clinic for treatment for cancer in
2016. But it quickly calmed her fears about
the radiation therapy she needed to go
through, which was causing her severe
anxiety.
"I felt the difference right away, I was much
more relaxed," she said.Ms. Justo, who has
been free of cancer for over four years,
continued to visit the hospital every week
before the onset of the pandemic to work
with Mr. Rossetti, whose gentle guitar riffs
and visualization exercises helped her deal
with ongoing challenges, like getting a good
night's sleep. Nowadays they keep in touch
mostly by email.
The healing power of music - lauded by
philosophers from Aristotle and Pythagoras
to Pete Seeger - is now being validated by
medical research. It is used in targeted
treatments for asthma, autism, depression
and more, including brain disorders such as
Parkinson's disease, Alzheimer's disease,
epilepsy and stroke. Live music has made its
way into some surprising venues, including
oncology waiting rooms to calm patients as
they wait for radiation and chemotherapy. It
also greets newborns in some neonatal
intensive care units and comforts the dying
in hospice.
While musical therapies are rarely standalone
treatments, they are increasingly used
as adjuncts to other forms of medical
treatment. They help people cope with their
stress and mobilize their body's own capacity
to heal.
"Patients in hospitals are always having
things done to them," Mr. Rossetti
explained. "With music therapy, we are
giving them resources that they can use to
self-regulate, to feel grounded and calmer.
We are enabling them to actively participate
in their own care."Even in the coronavirus
pandemic, Mr. Rossetti has continued to
perform live music for patients. He says that
he's seen increases in acute anxiety since the
onset of the pandemic, making musical
interventions, if anything, even more
impactful than they were before the crisis.
Mount Sinai has also recently expanded its
music therapy program to include work with
the medical staff, many of whom are
suffering from post-traumatic stress from
months of dealing with Covid, with live
performances offered during their lunch
hour.
It's not just a mood booster. A growing
body of research suggests that music played
in a therapeutic setting has measurable
medical benefits."Those who undergo the
therapy seem to need less anxiety medicine,
and sometimes surprisingly get along
without it," said Dr. Jerry T. Liu, assistant
professor of radiation oncology at the Icahn
School of Medicine at Mount Sinai.