InnerHealth MD

11/11/2024

As winter approaches, especially here in the more northern latitudes where the sky is dark before 6pm by now, it's particularly important for us to cultivate 3 areas of life: exercise, creativity and social connection in person.

Many people find themselves retreating into more confined lives in winter. These months of relative isolation take a toll on the spirit and body.

So here in the late autumn, take stock of some ways you could stoke the fire of all three areas in yourself.

Exercise - blend a routine mix of aerobic (walking daily, jogging, indoor stationary bike, snowshoe, cross country skiing) and strength training (weights, yoga, Pilates, core strengthening).

Creativity - try out a new art form or revive a familiar but neglected one like poetry, short stories, drawing, painting or music (I recently returned to drumming after a years-long hiatus). Don't be afraid of not being good at it! Just try it out.

Social connection in person - set a regular weekly gathering with a few friends for a book club, a movie night, ritual of watching a weekly sports game on TV or attending one out in the community, a church service. Go out to an open mic night. Play cards.

Even best is spending time with others in service (there are so many local nonprofits who need volunteers - Hunger Coalition, Mountain Humane, and others). 

Keep it simple and make it regular so it becomes an ordinary thing in your winter life.

The difference in one's life come April and May after a winter of relative isolation and inactivity versus winter of intentional cultivation of exercise, creativity and social connection in person with others can easily mean the difference between struggling and thriving as the winter thaws and spring arrives.

Get out and be well!!

01/15/2022

Raised in Hailey, ID by Valerie Skonie, the annual 40-day Feast for the Soul starts this weekend. Check it out!

The Feast for the Soul is a dedicated 40-day spiritual practice intensive which unites people worldwide in their commitment to deepening their practice.Any form of peaceful spiritual practice is embraced. Join the more than 20,000 people worldwide who observe the Feast. It's cost-free and interdenom...

01/05/2022

InnerHealthMD Pulse - January 2022 - https://mailchi.mp/d4e731323b96/innerhealthmd-pulse-january-14861392

12/02/2021

Regarding COVID19 vaccination availability:

The general availability of the Moderna COVID19 vaccine in the state of Idaho has run low, and what is at pharmacies/offices is what is available until further notice.

Here at InnerHealthMD, we have 4 bottles of the Moderna vaccine remaining (20 booster doses per bottle), and we will be administering those on Wednesday each week in December (December 8, 15, 22, 29).

We offer Pfizer/BNT vaccination 2-3 days per week, and there is plenty in stock.

We offer COVID19 vaccination to our practice and to the general public. People can schedule by calling 208-578-4550.

11/17/2021

Topics: COVID-19 Vaccine access (including age 5-11 yrs), rationale for boosters, mixing-matching, and current viral illness patterns circulating in the Wood River Valley.

COVID-19 vaccinations are available at InnerHealthMD to both our patients and to the general public, for ages 5 and up.

- The PfizerBNT vaccine is available at our office typically 2-3 days per week.
- The Moderna vaccine is available at our office typically 1 day per week.
- We do not administer the Janssen vaccine.

To schedule COVID19 vaccination at InnerHealthMD, call 208-578-4550.

Cost of COVID-19 vaccination at InnerHealthMD: Free. This is a public service.

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Vaccination is also available at local pharmacies, Sterling Urgent Care, St Luke's, and other medical practices for certain ages and by appointment. The exception to this is that is for children aged 5-11yrs - that varies by location as below:

Age 5+: InnerHealthMD and St Luke's. (I am not aware of others offering vaccination for 5 year olds.)
Age 6+: Valley Apothecary
Age 12+: Luke's Pharmacy
Age 18+: Albertson's and the Drug Store at Atkinson's in Hailey

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I recommend COVID-19 boosters for adults after 6-8 months from the date of one's 2nd PfizerBNT/Moderna or 1st Janssen vaccine - certainly for those age 65+ or 18-64 with risk factors (there are many and are listed at the link below) or those at increased risk or exposure through work. (I am supportive of anyone age 18+ having a booster, and that recommendation will be coming soon nationally and is already the standard in several states.)

Risk factors: https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/people-with-medical-conditions.html

I have about 1-3 patients per week with new COVID-19 infections lately, including mostly unvaccinated along plus some previously vaccinated individuals. The frequency of so-called "breakthrough" infections is starting to pick up, though my previously vaccinated individuals who get COVID-19 infection are very typically not nearly as ill as those not vaccinated. Vaccination remains highly effective at reducing severity and is also quite effective at reducing any infection, though certainly not completely, especially as time increases from date of vaccination.

At the beginning of the pandemic, the definition of a "successful" vaccine was projected as being one which reduced by at least 50% the chance of hospitalization and death. COVID-19 vaccines have performed extraordinarily well. However, the perception that they should be infallible against any infection is incorrect. There is a mixture of evidence that vaccinated individuals with symptomatic COVID-19 infection are infectious for shorter periods than the unvaccinated.

I expect that, for the mRNA vaccines (PfizerBNT and Moderna), the 3rd dose will likely be the last one at least until Fall 2022 and possibly longer - time will tell.

A word on using COVID-19 antibody tests - they have a small, limited range of clinical usefulness. However, they are not useful at all for deciding whether to have a booster vaccine (unless negative despite prior vaccination). The useful things to consider when considering having a booster vaccine are a) risk of exposure to infection, b) risk of moderate to severe infection to self, c) potential consequences of infection to self and others, and d) time from 2nd Moderna/PfizerBN or 1st Janssen vaccine.

Mixing and Matching. This refers to having a booster with a different brand of COVID-19 vaccine than originally received. Based on available data, the strongest immune response is seen when Moderna is given as the booster, regardless of what one's original COVID-19 vaccine was. The difference between using Moderna as the booster after Pfizer/BNT instead of continuing with Pfizer/BNT as its booster is not huge; however, Moderna significantly outperformed Pfizer/BNT when they were compared for use as a booster after Janssen vaccination.

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Viral patterns currently circulating locally in the Wood River Valley:
1) COVID-19
2) Rhinovirus - common head cold
3) Adenovirus - flu-like illness with fairly intense sore throat, fevers, aches/pains, cough. There appears to be a lot of this circulating (based on some adenovirus positive tests, as well as the severity of the viral syndrome testing negative for COVID-19 and influenza)
4) Gastroenteritis - nausea/vomiting followed by diarrhea (some are just getting the diarrhea)
5) Influenza - I am aware of one case of influenza B per communication with another physician; I have not seen any positive flu tests yet. Furthermore, the Idaho state lab reports only 1 case tested positive there so far this season (influenza B ).

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About vaccinating children for COVID-19:
The study of ~2300 children in the 5-11 yr old range receiving the 10mcg PfizerBNT vaccine (two doses, 3 weeks apart) was promising in terms of immune response being similar to 16-25 year olds who received the 30mcg vaccine dose twice. There were not enough children to show any findings of myocarditis, simply because the incidence of that is so much smaller that you'd need to vaccinate about a million children to see a statistically significant number of cases (if they appear with statistical significance in children with this dose). In the older groups aged 12+yrs, it was the boys who were more likely to have myocarditis and that problem was self limited - described as much milder than the viral-induced myocarditis that we occasionally see (not that common but I've seen a few cases in my career from viral infections, though I've not seen them from vaccines in my experience yet).

The reasons to vaccinate include 1) protection from the relatively uncommon severe COVID19 infection leading to hospitalization and some deaths, 2) reduction of the pool of people who can spread SARS-CoV-2 in terms of general pandemic management, 3) reduction the chance of horizontal spread to other children or vertical spread to older household adults, particularly given the grim statistic that >150,000 American kids have lost a parent or caregiver to COVID-19 infection. Add to this the more mundane effect on one's ability to travel, participate in team sports, and reduce the chance of missing school for extended periods due to infection or close contact exposure.

Overall, I think the aggregate risk/benefit balance favors vaccination of children in the 5-11 year old age range. This is small consolation for someone injured by vaccination. However, severe vaccine injury is rare, and I have not seen this occur. (I don't consider fever, sore arm, fatigue, aches, headache, or lymph node swelling to be in the severe category, though these certainly can be unpleasant for days or rarely longer.) Eventually by about 2025, I expect that nearly everyone will either have had COVID-19 infection, vaccination, or in some cases both (though infection in a vaccinated person is typically much easier to navigate and a safer bet).

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Traveling in close proximity to others not in your household? Wear your best mask (preferably N95 material) whenever unable to distance from others, and if you wear glasses, wear them in closed indoor spaces along with your mask. (PS: it is well past time to move on from cloth masks to surgical paper masks or N95 fabric paper masks if available and close-fitting. They simply work better both on the inhale and the exhale.)

Hosting a dinner? Open a window or two on opposing walls to encourage ventilation. Stay home if you have cold symptoms. Keep your dinner small in number, and encourage individual responsibility for not bringing cold symptoms or recent exposure to Thanksgiving dinner. Accept the risk you are willing to take (for yourself and for others you might unknowingly infect), and minimize that risk as best you can.

COVID-19 will be with us for a long time. It is hoped and expected that the accumulating combination of vaccination and immune response to infection is gradually building a broad societal level of durable immune response such that future waves of COVID-19 infections grow smaller, shorter, and less severe.... fingers crossed! (A big factor in this depends on the US and Europe stepping up genuine efforts to help vaccinate of the rest of the world, so as to reduce the rate of clinically-significant mutation variants.)

Please be kind, patient, and considerate with all others - it's worth it to preserve relationships!

Happy Thanksgiving!
Tom Archie and staff at InnerHealthMD

10/29/2021

Happy Halloween from the carnival at InnerHealthMD

10/20/2021

Happy Halloween, during all of October, from the carnival at InnerHealthMD! Zoltar says, “your wish is granted!”

09/28/2021

Hello from InnerHealthMD,

Having received many good questions about COVID-19 vaccines, here is the short version of my update on this topic….

- Individuals vaccinated against COVID-19 are 5 times less likely to get infected with COVID-19, 10 times less likely to be hospitalized for COVID-19, and 11 times less likely to die from COVID-19.

- It is increasingly apparent that nearly everyone will either get COVID-19 (more than once) or be vaccinated (or both). The delta variant is much, more more infectious than earlier SARS-CoV-2 variants. Natural immunity varies by 200-fold and lasts as long as about 8-12 months (only 18% of Ketchum seroprevalence study participants with COVID19 infection still had detectable antibodies after 10 months). COVID-19 is mild for some, moderate for many, severe for a sizable few, fatal in a small percentage but large number of people, and causes chronic fatigue and other chronic symptoms in about 20-30%. It is unlikely that the 2020s decade passes with a large portion of the population having neither been infected with SARS-CoV-2 nor vaccinated against it, and most of those will likely either be living in a very highly-vaccinated local population or be living in a very rural, socially-isolated setting.

- COVID-19 vaccines are remarkably effective and safe; there is no statistically significant chance of death from receiving a COVID-19 vaccination. Though rare significant harm likely occurs, the odds of that are exceptionally and inconceivably small in scale. There are commonly reported side effects (sore arm, aching, fatigue, chills, headache), less commonly reported side effects (vertigo), and incredibly rare reported severe adverse events (myocarditis, blood clots, Guillain-Barre syndrome). No observable adverse impact on pregnancy has been observed, and infants born to vaccinated pregnant women all have measurable antibodies against COVID-19 infection.

- PfizerBNT 30mcg 3rd dose booster has been approved by FDA and CDC for the following:
1) Anyone 65 years of age or older
2) Anyone 18-64 years of age with medical conditions that put them at high risk of severe COVID-19 infection (including cancer, chronic kidney disease, lung disease such as COPD or asthma, coronary artery disease, hypertension, heart failure, HIV, dementia or other degenerative neurological condition, immunocompromised state, alcoholic or non-alcoholic liver disease, overweight with BMI 25-29, obesity with BMI > 30, pregnancy or recently post-partum, current or former to***co smoker, recipients of organ or bone marrow transplant, stroke or cerebrovascular disease, substance abuse disorders)
3) Anyone 18-64 years of age who is at high risk for occupational exposure (workers in health care, grocery, teachers, prisons, for example)

- Moderna’s and Johnson & Johnson’s booster data are pending review by FDA and then the CDC. I recommend waiting for that data to be released and FDA/CDC recommendation made before having 3rd Moderna or Janssen booster vaccine unless circumstances related to an immunocompromised state warrant consideration.

- It is anticipated that Moderna’s booster 3rd dose will probably be a half dose (50mcg rather than 100mcg given for the first two doses).
1) Any Moderna booster given at this point (recommended thus far for people with immunocompromised states) remains a full dose (100mcg) until that data has been reviewed and decision announced. A 100mcg dose would likely cause more immunogenic side effects than a 50mcg dose.
2) Johnson & Johnson has announced that it is requesting approval for a booster 2nd dose at or after 6 months from the first dose.

- Neither PfizerBNT, Moderna, nor Johnson & Johnson have announced whether there was a significant difference between the immune response versus the delta variant for those people receiving booster doses of their original vaccine versus their updated vaccine.

- Timing of boosters: I don’t feel that getting a booster "now" is a particularly urgent issue outside of those at greatest risk of severe infection (elderly and underlying conditions). I do think that having a 3rd mRNA PfizerBNT or Moderna (or a 2nd DNA Janssen) vaccine dose is a good idea as we get closer to 12 months after full initial vaccination. I do not expect that a 4th dose will be needed for at least a year afterward, or possibly quite a bit later than that. Time will tell.

- “Mix and Match”
It is not yet known whether it is better to give a booster dose with the same vaccine brand that a person received initially or whether it is better to cross over vaccine/booster combinations (referred to as “mix and match”), because all the studies have been with single-line vaccines (PfizerBNT-PfizerBNT and Moderna-Moderna). For now, I recommend that vaccine boosters be given consistent with the original vaccine received. In the meantime, the NIH began a “Mix and Match” study in June. Results probably won’t be published until next winter/spring.

- Children 55yo participants
- Completed PfizerBNT + booster Moderna
- Completed Moderna + booster Moderna
- Completed Janssen + booster Moderna
- Previously unvaccinated - standard Moderna 1st/2nd dose, then booster Moderna 12-20 months later (unless updated per Fall 2021 FDA/CDC Moderna booster timeline recommendations).

Novavax’s COVID-19 vaccine has been studied in >30,000 people, found to be 90.4% effective in preventing COVID-19 infection and reportedly has a better side effect profile compared with current vaccines (which are themselves very safe but do commonly cause several days of fatigue, chills, and aches in many, some other less common side effects in a sizeable minority, and incredibly rare instances of heart inflammation, blood clots, or neurological effects). It is a more traditional form of vaccine, delivering copies of the coronavirus spike protein to the body directly so as to provoke an immune response to the spike protein (rather than delivering mRNA so that our cells can make the spike protein first and then generate an immune response to it). While Novavax anticipates an ability to produce 2 billion doses a year by sometime in 2022, it has postponed applying for FDA approval until December 2021 or later, due to production scale issues. It has applied for approval by the World Health Organization and can be transported and stored at refrigeration temperatures, making it likely to benefit rural and underserved populations around the world.

Here is some information on COVID-19 vaccine safety with a focus on safety in children….

Summary:
While rare reports of significant harm by COVID-19 vaccines have been described and are summarized below, COVID-19 vaccines have a very good record of safety and effectiveness and represent a very important means of reducing deaths and hospitalizations, reducing the impact of pandemic on our economy and general way of life, and reducing the emergence of variants by reducing the number of people infected.

Mortality:
In regards to vaccine safety, fatality rates among the >100,000 study participants in the combined COVID-19 vaccine trials indicated that there is no vaccine-associated mortality compared with unvaccinated individuals. However, vaccinated individuals are 5 times less likely to get infected with COVID-19, 10 times less likely to be hospitalized for COVID-19, and 11 times less likely to die from COVID-19.


Myocarditis:
While there are rare serious adverse effects that can certainly harm, these are remarkably rare and almost always self-limited. There have been rare cases of inflammation in the heart in youth called myocarditis. For every 1 million COVID-19 mRNA vaccine doses given, there have been 67 cases of myocarditis in boys aged 12 to 17 (nine in girls of that age group), 56 in those aged 18 to 24 (six in girls), and 20 in males 25 to 29 (three in girls). That means the risk is about 6-7 per 1,000 in those age groups combined. Overall there have been 669 confirmed cases of myocarditis or pericarditis out of >300 million COVID-19 vaccine doses.

Blood Clots:
The risk of developing a blood clot following administration of the Janssen vaccine has been reported to be 39 cases out of >13 million doses as of July 2021, mostly in women 13 million doses of Janssen vaccine. This condition is rarely seen in response to a number of viral infections and rarely associated with other vaccinations.

Safety in Pregnancy:
A observational study of pregnant women receiving COVID-19 vaccination published in June 2021 in the New England Journal of Medicine included 35,691 pregnant women aged 16-54 yo and found no difference in adverse pregnancy and neonatal outcomes compared with studies involving pregnant women that were conducted before the COVID-19 pandemic. No report of nor proposed mechanism of action of persisting harm to reproductive health has been described.

Lastly, here is a sobering thought on COVID-19 in the years to come...

Consider measles. You can get it only once or you can have a pair of two vaccines - either way, immunity lasts a lifetime. Measles is crazy-infectious; it is an R0 of 12-18 (meaning that, on average, one infected person will infect 12-18 others). The percentage of society that must be vaccinated in order to prevent a measles epidemic is ~94% (for just a two-dose vaccine series for lifetime immunity).

Coronaviruses (the common cold ones and SARS-CoV-2) can infect someone about every 10-18 months or so. "Natural" immunity to COVID-19 varies by 100-200-fold in quality and wanes away by about 10-12 months in most. mRNA vaccine response duration is not known but based on the 6 month data, may last about 18 months (wild guess there, since the first ones were given about a year ago). The Delta variant of SARS-CoV-2 has an R0 of 6-9 (meaning one person can infect 6-9 others); this compares with the original SARS-CoV-2 virus which had R0 of about 2.2-2.9. Influenza has an R0 of about 1.3-1.8, maybe as high as 2). We didn't see influenza last year here locally, because we got serious about masking and distancing at the right times.

With measles having R0 12-18 and requiring ~94% vaccination rate to prevent epidemic outbreaks (of an infection that you can only get once), it seems likely that the delta variant of SARS-CoV-2 with its R0 of 6-9 would require a combined vaccination rate PLUS recent-last-year infection rate of somewhere in the range of maybe 80-88% (my best guess as a non-epidemiologist).

With such a huge number of people refusing COVID-19 vaccination, assuming that mass bad decision persists, it will take some 15-18% of the population getting infected with COVID-19 roughly every 1-2 years (about 30-50 million a year), along with 65-75% of us continuing to vaccinate at what could be 12-24 month intervals (wild guess, depending on duration of immune response to 3rd mRNA dose, ie: booster).

Living with COVID-19, masking/distancing when needed, vaccinating when it's time; rather than be "over it", get "good at it."

That wraps up this COVID-19 vaccine update.

Be safe, stay well, protect others, and be radically kind to everyone - meaning everyone.

Tom Archie MD
InnerHealthMD