The Christine
Unsalvageable
“The VA system is a lot different than here, you know,” the man said. I nodded and then asked him if he would tell me more.
When I had first entered the exam room, he had been pacing the floor, looking out the only window and wringing his hands. I approached him slowly, with a big smile on my face, and greeted him while standing and craning my neck up to see his face. We chatted in place for a second, and I asked him for the paperwork which he had filled out and left on his chair. Only once he sat, did I sit on my round wheely seat and relax my strained neck muscles. I had a meeting I needed to remember to get out in time for, but I could tell this encounter was not going to be easy. I noted I would have to ask him to remove his leather jacket to hear his lung sounds and that his light grey hair was unnaturally yellowed around his face.
I asked him all the normal questions, making sure to get a history of what had changed since he last visited this doctor. Many times, he did not know the answer to seemingly simple things. I tried looping back around, to see if I could help him feel more comfortable with me in order to help him remember. If anything, that seemed to confuse him.
“The VA system is a lot different,” he was saying. “There, when a doctor gives an order, it’s like a real order, you know? Like you could get court marshalled for not following it, right?”
He related his story to me, one that involved a horrible accident and subsequent testing at various military hospitals. He said he went through months of seeing different doctors in many different states, until finally the military reached a decision about his fate.
“The last doctor told me I was unsalvageable, so I got discharged,” he said, nonchalantly.
“Unsalvageable?” I said, my jotting hand frozen. “They used that word?”
“Yeah,” he replied. “You know, the military talks different.” But the lines in his face softened, and the tone of his voice almost broke. His left hand started twitching rhythmically, and he looked deep into my face, searching for something.
“Right, but, that’s still hard. That sounds like a really tough time for you,” I responded, unsure of what he was looking for. Apparently he found it, because he smiled and leaned back, twitch ceased.
I learned a lot from that man, and to be honest I missed that very important meeting I was supposed to rush through that encounter to attend. Perhaps I should have been intimidated. He was, after all, a foot taller than me and obviously agitated by his surroundings. I did not get a detailed history and could not answer all the questions my attending asked me, but I think the encounter was successful nonetheless. I learned a lot, and I hope that he felt seen.
How healing, how therapeutic is being seen.
~Yahweh El Roi Genesis 16:13~
The Moonrise
The Hemlock
Vitamin D Supplementation
Before I get into the meat of this post, first let me explain that this paper was written as part of my Lifestyle Medicine rotation. It was born out of my desire to truly seek whether or not the evidence supports various commonly-recommended supplements. It was written with the audience in mind of fellow medical students and physicians.
Vitamin D – A brief review of current recommendations and evidence
Among popular health advice is the recommendation to take daily vitamin D supplements. This advice is generally backed by reports of widespread deficiency in the fat-soluble vitamin and lists of bodily functions in which it participates. When coupled with statistics on the rarity of hypervitaminosis D and claims that few foods contain sufficient amounts, supplementation seems like the obvious conclusion. But is it? Perhaps a closer look is warranted.
A general principle of replacement therapy is to give supplementation only to patients who have documented deficiency so that therapy can be justified. The definition of vitamin D deficiency is generally considered less than 20 nanograms per milliliter [1]. The most commonly cited reason for deficiency is a lack of adequate sun exposure, which can occur by sun avoidance, sunscreen overuse, very modest clothing styles, darker skin tones or living too far away from the equator for optimal light angle. Other causes for deficiency include obesity, fat malabsorption syndromes, prior bariatric surgery, nephrotic syndrome & medications like anticonvulsants and antiretrovirals [2].
Even in the absence of these risk factors and conditions, many people are taking vitamin D supplementation regardless of clinically documented deficiency status [3, 4]. While vitamin D was not the only supplement turned to in the chaos of the recent coronavirus pandemic, the supplement business was a nearly $60 billion industry in 2021 and has been a very lucrative industry for decades [5], leading some to ponder the origins of claims regarding supplement benefits. Many of the claims circulating in popular culture about the benefits of vitamin D are based on the logical fallacy of the inverse, where one assumes that because an association has been seen between the presence of deficiency and the presence of a disease state, there must also be an association between the absence of deficiency and absence of said disease state. Many of these claims have now been well studied and found to be inaccurate, but some are of note to today’s health professionals.
Claims
Prevention of Fracture – While the physiology involved in the claim that vitamin D supplementation could prevent fractures is beyond the scope of this review, various resources on the topic are available to the curious reader [1, 2]. This claim is perhaps the most prevalent of those here examined, but the body of evidence does not support it. The recent randomized, controlled Vitamin D and Omega-3 Trial (VITAL trial) reported an ancillary study showing no decreased risk of fractures could be found between vitamin D supplementation and placebo groups in 25,871 generally healthy participants over 5 years of follow-up [6]. This trial is the largest to date, and it is considered by some to be the definitive answer on the subject of vitamin D supplementation benefits [7], but experts have predicted this outcome for some time now. The 2018 US Preventative Task Force (USPTF) published recommendations stating that there is inadequate evidence to support supplementation of vitamin D, calcium, or both to prevent fractures in general populations. The USPTF does specify doses of 400 IU of vitamin D and 1000 mg of calcium were studied and that this recommendation applies to premenopausal women and community-dwelling men in this edition of their report [8]. Part of the evidence base the 2018 USPTF had included a 2014 Cochrane review which found a number needed to treat of 1000, indicating that supplementation with both vitamin D & calcium had little benefit to preventing fractures [9]. The USPTF reminds readers, though, that screening for osteoporosis to prevent fractures is recommended in both young women at risk and all post-menopausal women over the age of 65 [10].
Further analysis has gone into specifying if vitamin D supplementation could prevent falls, as a noted symptom of deficiency is muscle weakness [1]. While the USPTF found no benefit for vitamin D supplementation in preventing falls in the elderly, they did find B-level evidence that physical exercise interventions do have some benefit here [11].
Prevention of Cardiovascular Disease and Cancer – Although these two disease categories are distinct from each other, many observational studies looked at both endpoints. An ancillary report from the aforementioned VITAL study found that cholecalciferol (vitamin D3) at a dose of 2000 IU per day did not lower incidence of either invasive cancers or cardiovascular events compared to the placebo at 5 years [12]. Again, this is a strong, recent finding but was predictable from previous reviews and recommendations. A Cochrane review from 2014 stated that there was no firm evidence as to whether vitamin D supplementation increased or decreased cancer incidence [13] and the USPTF found insufficient evidence for any multivitamin to prevent cancer [14].
Prevention of Other Undesirable Conditions – Further claims that vitamin D supplementation can prevent infections in young children and dementia in aging adults were also examined and found wanting [15, 16].
Management of Known Conditions – With the recent coronavirus pandemic, there was an insurgence of vitamin D supplementation due to claims that it could mitigate the severity of COVID-19 infection, either prophylactically or for secondary prevention. However, there is still insufficient evidence to evaluate this claim [17].
Multiple sclerosis is noted to occur more commonly in people with vitamin D deficiency [18]. While no clinical trials have examined if vitamin D supplementation can prevent the disease, there are several examining management [19]. Although a 2018 Cochrane review found the evidence to be low quality, reviewers concluded that there was no difference from placebo [18].
Interestingly, there is some evidence for the management of asthma with vitamin D supplementation. While the evidence base is still growing and physicians are advised to wait before recommending it to patients [20], a few reviews have found reduced risk of asthma exacerbations leading to hospitalization [21] and incidence of acute respiratory infections in those with asthma and COPD with vitamin D supplementation compared to placebo [22]. Optimum dosing and further studies are still needed, but this is an interesting area for continued research.
In pregnancy, there is some evidence that vitamin D probably reduces the risk of preeclampsia, gestational diabetes and low birthweight, and may even reduce the risk of severe postpartum hemorrhage [23]. The USPTF recommends taking aspirin for prevention of preeclampsia [24]. Although vitamin D deficiency is common in both pregnant women and their neonates, insufficient evidence exists for giving vitamin D to neonates to improve bone health, either directly or through lactating mother [25].
So, should we supplement?
For select patients, the answer is absolutely. In the setting of clinical deficiency, treatment is often warranted. In children with documented deficiency, aggressive treatment may be needed to prevent rickets [2]. Those at risk for deficiency were listed above and should be screened regularly by their physicians. In the setting of chronic kidney disease, 25-hydroxyvitamin D levels should be measured annually [1]. In the setting of malabsorption, hepatic failure or chronic use of anticonvulsants, glucocorticoids or other drugs that activate the steroid & xenobiotic receptors repletion of vitamin D may require higher doses. Pregnant and lactating women are recommended to take 400 IU of vitamin D3 per day [1]. However, both USPTF and the Endocrine Society recommend against screening for vitamin D deficiency in those not considered at risk [26, 2].
It cannot be dismissed, however, that multiple undesirable conditions are associated with low vitamin D levels [19]. This knowledge may lead to the further question of, “is there anything to do, then?” There is room for improvement in a few areas of the standard American lifestyle.
As vitamin D is often called the “sunshine vitamin,” [27] it is commonly known that sun exposure can help prevent deficiency. Specifically, sunlight hitting the skin between 10am & 3pm during the spring, summer & fall that causes the skin to have a slight tone change for 24 hours after exposure provides ample production of the vitamin for most people. However, people who live above or below latitudes of 33 degrees may not be able to obtain enough sunlight. During the winter and in regions without enough sun, tanning beds used for 30-50% of the time used to tan can also help [1].
Other lifestyle changes to be made include weight loss, as adiposity is a risk factor for deficiency [28], and dietary modification. Despite popular confusion on optimum dietary parameters, there is a significant consensus in dietary evidence supporting that Americans need to eat fewer calories from solid (or saturated) fats, added sugars and refined grains and consume more fruits, vegetables and whole grains [29, 30]. This dietary pattern has been well-proven to decrease risk for CVD & multiple types of cancers, as compared to the lack of evidence supporting supplementation with Vitamin D to prevent the same [29]. Incorporating food items known to have significant amounts of vitamin D may help people achieve the recommended daily intake. For people between the ages of 1 & 70 years, the recommended dietary allowance is 600 IU [31]. Foods that are good sources of vitamin D include fish such as salmon, sardines, mackerel & tuna, mushrooms, egg yolks & fortified foods [1]. Most fortified foods are dairy products, including milk, yoghurt, cheese and butter, but plant-based sources include lichen & mushrooms [32].
While many of claims regarding vitamin D supplementation have been proven false, the persistence of an association between vitamin D deficiency and certain disease states presents a conundrum which popular logic solves by daily, safe-dosed supplementation. The symptoms of hypervitaminosis D are usually only seen at regular intakes far and above recommended daily intake and surveys point to less-than-adequate dietary intake of the vitamin [1, 31, 27, 19]. It seems pertinent to consider daily supplementation of 400-600 IU rather safe, so long as patients are not expecting the grandiose results promised by false claims. While benefits of daily supplementation are not supported by current literature, discussions where patients bring up vitamin D may provide an opportunity to discuss lifestyle-based methods of improving nutrition and health. Since human skin synthesizes vitamin D during sun exposure, increased vitamin D serum levels is a wonderful benefit to exercising outdoors. Since dietary intake of the vitamin is commonly low in Americans, increased fish & whole food intake are aligned both with the goal of increasing vitamin D and following well-proven diets like DASH and Mediterranean. Perhaps the best use of consultation time in discussion of the vitamin is simply promoting healthy lifestyle behaviors and not recommending potentially costly supplementation.
References
| [1] | M. Holick, “Vitamin D Deficiency,” New England Journal of Medicine, no. 357, pp. 266-281, July 2007. |
| [2] | M. Holick, N. Binkley, H. Bischoff-Ferrari, C. Gordon, D. Hanley, R. Heaney, H. Murad and C. Weaver, “Evaluation, Treatment, and Prevention of Vitamin D Deficiency: an Endocrine Society Clinical Practice Guideline,” J Clinical Endocrinology & Metabolism, vol. 96, no. 7, pp. 1911-1930, July 2011. |
| [3] | M. Rooney, L. Harnack and E. Michos, “Trends in Use of High-Dose Vitamin D Supplements Exceeding 1000 or 4000 International Units Daily, 1999-2014,” JAMA, vol. 317, no. 23, pp. 2448-2450, 2017. |
| [4] | K. Herrick, R. Storandt, J. Afful, C. Pfeiffer, R. Schleicher, J. Gahche and N. Potischman, “Vitamin D Status in the United States, 2011-2014,” Am J Clinical Nutrition, vol. 110, no. 1, pp. 150-157, 2019. |
| [5] | Nutrition Business Journal, “Supplement Business Report 2022,” New Hope Network, 2022. [Online]. Available: https://store.newhope.com/products/supplement-business-report-2022. [Accessed 22 September 2022]. |
| [6] | M. LeBoff, S. Chou, K. Ratliff, N. Cook, B. Khurana, E. Kim, P. Cawthorn, D. Bauer, D. Black, C. Gallagher, M. Lee and J. Buring, “Supplemental Vitamin D and Incident Fractures in Midlife and Older Adults,” NEJM, vol. 387, pp. 299-309, 2022. |
| [7] | S. Cummings and C. Rosen, “VITAL Findings – A Decisive Verdict on Vitamin D Supplementation,” NEJM, vol. 387, pp. 368-370, 2022. |
| [8] | US Preventative Task Force, “Vitamin D, Calcium, or Combined Supplementation for the Primary Prevention of Fractures in Community-Dwelling Adults,” JAMA, vol. 319, no. 15, pp. 1592-1599, 2018. |
| [9] | A. Avenell, J. Mak and D. O’Connell, “Vitamin D and vitamin D analogues for preventing fractures in post-menopausal women and older men,” Cochrane Database of Systematic Reviews, no. 4, 2014. |
| [10] | US Preventative Task Force, “Final Recommendation Statement on Osteoporosis to Prevent Fractures: Screening,” 26 June 2018. [Online]. Available: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening. [Accessed 21 September 2022]. |
| [11] | USPTF, “Interventions to Prevent Falls in Community-Dwelling Older Adults,” JAMA, vol. 319, no. 16, pp. 1696-1704, 2018. |
| [12] | VITAL Research Group, “Vitamin D Supplements and Prevention of Cancer & Cardiovascular Disease,” NEJM, vol. 380, pp. 33-44, 2019. |
| [13] | G. Bjelakovic, L. Gluud, D. Nikolova, K. Whitfield, G. Krstic, J. Wetterslev and C. Gluud, “Vitamin D supplementation for prevention of cancer in adults,” Cochrane Database of Systemic Reviews, no. 6, 2014. |
| [14] | USPTF, “Vitamin, Mineral, and Multivitamin Supplementation to Prevent Cardiovascular Disease and Cancer,” JAMA, vol. 327, no. 23, pp. 2326-2333, 2022. |
| [15] | M. Yakoob, R. Salam, F. Khan and Z. Bhutta, “Vitamin D supplementation for preventing infections in children under five years of age,” Cochrane Database of Systematic Reviews, no. 11, 2016. |
| [16] | A. Rutjes, D. Denton, M. Di Nisio, L. Chong, R. Abraham, A. Al-Assaf, J. Anderson, M. Malik, R. Vernooij, G. Martinez, N. Tabet and J. McCleery, “Vitamin and mineral supplementation for preventing cognitive deterioration in cognitively healthy people in mid and late life,” Cochrane Database of Systematic Reviews, no. 12, 2018. |
| [17] | J. Stroehlein, J. Wallqvist, C. Iannizzi, A. Mikolajewska, M.-I. Metzendorf, C. Benstoem, P. Meybohm, M. Becker, N. Skoetz, M. Stegemann and V. Piechotta, “Vitamin D supplementation for the treatment of COVID-19: a living systematic review,” Cochrane Database of Systematic Reviews, no. 5, 2021. |
| [18] | V. Jagannath, G. Filippini, C. Pietrantonj, G. Asokan, E. Robak, L. Whamond and S. Robinson, “Vitamin D for the management of multiple sclerosis,” Cochrane Database of Systematic Reviews, no. 9, 2018. |
| [19] | National Institutes of Health Office of Dietary Supplements, “Vitamin D Fact Sheet for Health Professionals,” 12 August 2022. [Online]. Available: https://ods.od.nih.gov/factsheets/VitaminD-HealthProfessional/. [Accessed 21 September 2022]. |
| [20] | J. Qiu, “Vitamin D for the Management of Asthma,” American Family Physician, vol. 96, no. 5, pp. 290-291, 2017. |
| [21] | A. Martineau, C. Cates, M. Urashima, M. Jensen, A. Griffiths, U. Nurmatov, A. Sheikh and C. Griffiths, “Vitamin D for the management of asthma,” Cochrane Database of Systematic Reviews, no. 9, 2016. |
| [22] | D. Joliffe, C. Camargo, J. Sluyter, M. Aglipay and J. Aloia, “Vitamin D supplementation to prevent acute respiratory infections: a systematic review and meta-analysis of aggregate data from randomised controlled trials,” The Lancet Diabetes and Endocrinology, vol. 9, no. 5, pp. 276-292, 2021. |
| [23] | C. Palacios, L. Kostiuk and J. Pena-Rosas, “Vitamin D supplementation for women during pregnancy,” Cochrane Database of Systematic Reviews, no. 7, 2019. |
| [24] | USPTF, “Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality,” JAMA, vol. 326, no. 12, pp. 1186-1191, 2021. |
| [25] | M. Tan, S. Abrams and D. Osborn, “Vitamin D supplementation for term breastfed infants to prevent vitamin D deficiency and improve bone health,” Cochrane Databse of Systematic Reviews, no. 12, 2020. |
| [26] | USPTF, “Screening for Vitamin D Deficiency in Adults,” JAMA, vol. 325, no. 14, pp. 1436-1442, 2021. |
| [27] | Academy of Nutrition and Dietetics, “Supplements for Breastfed Babies,” AND, June 2021. [Online]. Available: https://www.eatright.org/food/vitamins-and-supplements/dietary-supplements/supplements-for-breastfed-babies. [Accessed 22 September 2022]. |
| [28] | S. Mallard, A. Howe and L. Houghton, “Vitamin D status and weight loss: a systematic review and meta-analysis of randomized and nonrandomized controlled weight-loss trials,” Am J of Clinical Nutrition, vol. 104, no. 4, pp. 1151-1159, 2016. |
| [29] | American College of Lifestyle Medicine, “A Family Physician’s Introduction to Lifestyle Medicine,” J Family Practice, vol. 71, no. 1, p. supplement, 2022. |
| [30] | L. Lesser, M. C. Mazza and S. Lucan, “Nutrition Myths and Healthy Dietary Advice in Clinical Practice,” American Family Physician, vol. 91, no. 9, pp. 634-638, 2015. |
| [31] | Institute of Medicine Committee to Reivew Dietary Reference Intakes for Vitamin D and Calcium, “Dietary Intake Assessment,” in Dietary Reference Intakes for Calcium and Vitamin D, Washington (DC), National Academies Press, 2011, p. Chapter 7. |
| [32] | W. Willett and D. Ludwig, “Milk and Health,” NEJM, vol. 382, pp. 644-654, 2020. |
COVID Vaccines: Q & A with Student Doctor Janae
COVID Vaccines: Q & A
Compiled by Student Doctor Janae
So, I’ve been asking people who are uncomfortable with the new COVID vaccines what their concerns were about them in order to attempt to answer with what we do (and don’t) know. As a medical student, I am very excited that we have a vaccine for this devastating disease. As a scientist, I want to know how it works, why it works, what are the side-effects, and many other questions which I have heard repeated in these conversations. I thought I might share a synopsis of what I learned, and a snippet of what I shared. Please take it as a consideration of risks and benefits, as every decision made in medicine (and life in general) is a balance of pros and cons.
I have studied human physiology, cell biology, immunology and many other relevant courses. I believe that informed consent is way too important to make this vaccine mandatory across the board, that understanding should be cultivated and respect should be mutual between patient and clinician. Whether you choose to get this vaccine or not is your choice, and I believe that should be respected. Also, please know that I am a student, not an expert, and will refer you to a clinician if you have specific health concerns.
And before we begin, let me encourage you, if you are my brother or sister in Christ, to begin with prayer. This is a stressful topic and one for which wisdom & clarity is needed.
Concerns Gathered
- It will change our DNA and we will never be able to get it out of our system.
- It will make women infertile, at least temporarily.
- It was made from aborted baby cells.
- It was developed way too fast.
- It will just mutate like the flu, so the vaccine won’t protect me.
- It may cause long-term effects or severe allergic reactions.
- Big Pharma is selling lies to make money off of these vaccines.
And if you have a concern which is not addressed here, please feel free to ask that question and if I don’t have an answer for you, I would be glad to do some research!
Biology Review
My references for this section are all of my biology textbooks. Feel free to skim this if you’re comfortable with this topic!
Cell Biology
I’ll start by a quick review of how our bodies are made and work normally. We are made of cells, and those cells are surrounded by a membrane which keeps them separate from other cells. This membrane is made of a phospholipid double layer mixed with cholesterol and a lot of proteins. (I promise those words are important!) Inside our cells, there are other membrane bubbles (also made of phospholipids) which need to be separate from the fluid inside the cell and other membrane bubbles in order to have their own function. One of those bubble is specialized and called the nucleus, which holds our DNA. As you know, DNA is our blue-print for making everything. It is double-stranded and stays inside the nucleus because our cells are very good at making sure the DNA stays in there, and they are also very good at protecting it from damage (cancer being when a cell fails to protect its DNA). In order to send the instructions from the DNA out to the space inside the cell but outside the bubbles, we need a molecule which is not DNA, because if it were DNA it would get shuttled back into the nucleus – the solution is mRNA. It has the same instructions but is different from DNA in a few very important ways, especially that it is single-stranded. Because it’s single-stranded it is not as stable as DNA is, and it will easily & quickly be degraded by proteins inside the cell which do that exact function all the time. mRNA can only survive in the cell for a very short period of time and the cell does not recognize it as something which belongs inside the nucleus, so mRNA cannot return to the nucleus.
Immunology
That’s the pertinent biology to how the vaccine will work. The pertinent immunology will follow. The first stage of an immune response starts with that every single cell in our bodies that has a nucleus also displays a “flag” of sorts on its membrane. This flag is called MHC or HLA, and its purpose is to display bits and pieces of the proteins which that cell is making. Normally it will display what we call “self” proteins, and the immune cells recognize the MHC flag holding self proteins and then decides that that cell is healthy and should be allowed to live. If a cell gets infected with a virus, the cell will start making the proteins that virus has instructions for and the cell will display “non-self” proteins on the flag. The immune cells then notice the non-self protein and decide that cell is not healthy and should be destroyed. That destruction process is what produces fever, achiness, swelling and redness, and we call those symptoms “inflammation.” Those symptoms simply mean the immune system is working on something in a very general way. The second step of the immune system’s response is when the immune cell (T cell) that noticed the infected cell’s flag travels to our lymph nodes to find its mate, another kind of immune cell (a B cell). B cells are extremely specific to particular offenders (called pathogens) and good at making similarly specific antibodies. This takes a while because there is only one B cell (or very few B cells, anyway) in the whole body which matches that activated T cell perfectly. After that B cell & T cell interact, the B cell grows and divides into lots of baby versions of itself, sending some to fight and some to train. This process is important, though, because it is how our bodies learn to fight pathogens and how we differentiate between different pathogens. Without antibodies being made, we would have the same response to any offender every time we encountered it. But if we make antibodies specific to a virus, those antibodies will engulf the offender and make it either easier for our body to fight or impossible for that offender to attack our body cells.
The body also responds differently to the offending pathogen on the second encounter with that pathogen than the first. During the first response, B Cells fight with whatever they already have. They send out a bunch of antibodies which work against the pathogen, but have not been honed against that pathogen. The B cells which got sent to training instead of the front line fight spend their time attempting to make their antibodies even better at attacking the pathogen of interest. (This process is called affinity maturation by somatic hypermutation.) This means that the second time the body encounters that same antigen, those better trained B cells will be leading the attack! (And this is the basis for immunity.)
Normal Vaccines
Now we can discuss vaccines–they usually have some part of an offender and some parts for preserving the offender and some parts for activating our immune response. Many people dislike vaccines because they contain some amount of aluminum or other toxins which are important for us to detox out of our bodies after the vaccine has trained our immune systems. These suspect-seeming components are included in the vaccine because our bodies know they are bad, and it makes the job of the T cells & B cells easier. If we inject something our bodies don’t know is bad, the chances of our bodies noticing it is lower than if we inject something our bodies do know is bad along with the new offender. We do use things which are toxic to humans, but we use those components in very small amounts, and we choose them because our bodies recognize them as bad. Sometimes the preservatives used are not particularly good for our bodies either, but the idea is that we are activating the immune system and the immune system will take care of eliminated those things. The offender which we are using the vaccine to train our bodies to fight is usually inactivated or made weaker in some way, but that changes depending on which vaccine we’re talking about. That’s normal vaccines. (My reference here is my immunology professor.) This COVID vaccine is different in multiple ways, but my favorite is that it does not have aluminum or any of those bad things in it because this vaccine uses our body’s system much more effectively. In the Pfizer vaccine, besides the mRNA & the carrier bubble, it just has salts and table sugar. (FDA Briefing on Pfizer Vaccine) I actually hope that future vaccines will be developed this way so that we have less toxicity in our vaccines!
mRNA Vaccines
So this vaccine’s active ingredients are just some mRNA (just like the mRNA in our normal cells which can’t return to the nucleus) surrounded and protected by something called a lipid nano- particle. This lipid nano-particle is nothing more than a bubble formed by the phospholipids & cholesterol which our cell membranes are made up of (FDA Briefing on Moderna Vaccine). The mRNA is made synthetically, from combining As, Us, Cs & Gs in a specific pattern with the right reagents. This process is a standard lab procedure that I completed in undergraduate. That mRNA gets into our cells when the lipid nano-particle fuses with our membranes. This happens just like you’ve seen oil bubbles on water surfaces. The oil bubbles like to fuse together. Similarly, the lipids in the nano-particle fuse with our cell membranes and since the particle is made of the same stuff the membranes are, our cells just monitor the membrane like normal. The mRNA then is translated just like our native mRNA would be, made into proteins, and those proteins are displayed on the MHC flag. When our immune system notices that these proteins are non-self, a response will occur just like I mentioned above. It’s a pretty beautiful way to use our knowledge of how the Lord designed the body’s natural immune system & biology! If you want visuals for this process, there are plenty! I recommend NinjaNerd for anyone, as he’s pretty much my favorite YouTuber (his video on COVID vaccines).
mRNA for the Receptor Binding Domain of the Spike Protein
What mRNA and protein does this vaccine use, and how did scientists decide to use that? I find this topic quite interesting. Scientists were able to determine what part of the virus first attaches to human cells and allows the virus to infect us (study). The protein on our cells which the virus needs to bind in order to infect us is called the ACE2 protein (study). Based on the structure of that protein and the genome which was sequenced early in 2020 (study), scientists were able to tell the RNA sequence which coded for the protein which interacted with ACE2 (called the spike protein) and use previous methods to make mRNA based on that DNA sequence. They chose to only use the portion of that spike protein which binds to ACE2, a portion called the Receptor Binding Domain (RBD; study), so that the spike protein version our cells make would not be the entire protein. A protein which does not have all of its parts is not usually able to do much at all, so it will be degraded by the cell. A non-functional protein is more likely to be degraded than a functional protein, so the chances of the cell choosing to display pieces of this spike protein on its MHC flag will be increased.
Here is a beautiful 3D diagram of what we know about what this virus looks like!
Concern #1: Effects on DNA
Since mRNA cannot travel into the nucleus, this vaccine cannot edit our genome. There is one vaccine being developed in the UK which uses DNA instead of mRNA, but I have not been studying that one very much. The two approved for Emergency Use in the United States are both mRNA-based, as was described previously.
*Update: a DNA-based vaccine has been given emergency use approval now; it is called the Johnson & Johnson vaccine. Still, I haven’t had the time to look deeper into this one, but from the studies I’ve read on it there are no increased risks with this type versus the mRNA types.
Concern #2: Fertility & Pregnancy*
The concern about reproduction is a more complex one. There are concerns that the protein which the mRNA is designed to make looks similar to some natural human proteins involved in the reproductive system, especially of females. I do not think this is a big problem because our bodies develop antibodies which are HIGHLY specific to the offender. There have been no studies done on the Pfizer vaccine relating to effects on the reproductive system and only a small number of studies done on the Moderna vaccine (and those only in rats). I want to see more studies on this because this is an important aspect of proving safety. The American College of Obstetrics & Gynecology actually recommends that any pregnant or lactating woman who wants to be vaccinated should be allowed to be vaccinated (their statement). That recommendation is based upon the known increased risk of severe disease due to the coronavirus when pregnant (study 1, study 2, study 3). Just as we want our seat-belts to be safety tested not because we know there’s a problem with the fabric, but because we want proof that there isn’t a problem with it, I want the vaccine testing to continue. I don’t have any reason to believe there will be any problems with it, but these tests haven’t been run yet and still need to be.
I would like to point out, however, that the likelihood of fertility complications from this vaccine would not be much different than the likelihood of fertility complications from getting the virus naturally. The spike protein used in the vaccine is the spike protein found on the virus, so if we develop antibodies to it from natural infection or from immunization the result is the same. So why get the vaccine? I’ll come back to that one, but in regards to fertility there has not been a spike in infertility to match the spike in COVID cases, so it wouldn’t make sense to say that a vaccine based exactly on one of the proteins in that virus would by itself cause infertility.
*Update (3/24/21): There have been some studies done now on the women who elected to get the vaccine based on the data I shared with you above! There were a lot of pregnant women in healthcare who saw the risk of severe COVID during pregnancy and chose to protect themselves & their babies. A study which is not yet published shows that in 84 (mostly white) pregnant patients who got the COVID vaccine, only 1 person had a fever in response to the vaccine, 1 woman had a pre-term delivery (1 in 84 is not higher than the normal expected rate) and there were no other reported adverse birth outcomes (no fetal growth restriction or preeclampsia). Additionally, there were 31 patients who were lactating at the time of vaccination. All of these patients saw a significant rise in their antibodies (just like the general population does), and especially in IgG-type antibodies. This is important because IgG is the only type of antibody which can cross the placenta and it provides the best protection of newborns out of all kinds of immunological protection. IgA is the only kind of antibody which is in breast milk, and it is a little helpful to newborns, but since it is in their food, their bodies digest those antibodies (as opposed to IgG which is in their blood when they are born). This study found that IgG was in the umbilical cord blood of almost all participants. IgA was observed in many particpants’ breast milk, but the IgA antibody formation was not as strong as the IgG formation. (Likely this is because the vaccine is administered in the muscles & not given as an oral preparation; see polio vaccines.)
Concern #3: Aborted Baby Cells*
I have spent hours in the cell culture lab working with cell lines. This technique was very opaque to me before I started, so let me explain what scientists do with cell cultures. The use of cells was developed in order to give scientists a means of observing what effects specific objects of study (a virus, a bacterium, a medication, etc.) has on a living cell. This is extremely important for safety testing, and before the development of cell lines, this research was only done on animals or embryonated eggs. That period of science history includes a lot of hard dilemmas regarding use of embryos, and an alternative was sought for. When scientists discovered that they could harvest cells from a living human and keep those cells alive perpetually, the game changed. They take a sample of cells and then nurture those cells in a solution which provides them with everything they need to grow. I spent weeks “culturing” cells, which means checking on them daily, feeding them at the right times, etc. The cells I worked with were taken from an African American woman who was being treated for cancer whose cancer cell sample was found to have an extraordinary ability to survive. Now, there is much concern that she and her family never were able to give consent for this use of her cells and that the profits from her cells have not been shared with them. (I did not know the history of these cells at the time of my experiments.) Science has a history which includes some dark choices, indeed. That cell line I worked with was one of many, many cell lines which are used today. Many of those cell lines do not have such ethical concerns in their history. Different kinds of cells are better for different kinds of research (study describing the use of cell culture and its history). Some cell lines in use for some research purposes are derived from aborted embryos, it’s true. Please note that in science, an “aborted” embryo is simply one which did not develop into a viable baby and has nothing to tell us about how that embryo died. However, those cells were taken from an embryo far in the past and the use of these cells does not sponsor any further addition to the cell line. The major benefit of using these cells is that they are all exactly the same, so adding any further donors would negate that benefit. While it is true that a baby once died and cells were harvested from its body, the cells which are used today are many generations down from that baby and do not contribute to the abortion industry today (Focus on the Family discussion with infectious disease specialists, please note the information below conflicts with a statement made by Dr. James).
Now, for the vaccine candidates against COVID19 there is a large chart developed (linked here) to show which cell lines were used for which vaccine candidate. Each cell line has a different history, so if you are interested in a specific cell line I would advise googling that specific one. Moderna used HEK293T/17, Vero E6, Huh7.5 & ACE2-expressing 293T cells (study) HEK stands for human embryonic kidney cells, and were derived from an embryo in the past, as was discussed above (study). It was started about 45 years ago (study). Vero E6 comes from monkeys, Huh7.5 are liver cells taken from a man with liver cancer, and the 293T cells are derivatives of the HEK293 cells mentioned above. Pfizer also used HEK293 cells (study). Both companies used these HEK cells only during the confirmatory testing phase, meaning that the vaccine was not made with these cells, only tested on these cells for safety.
*this information was updated on 12/27/2020
Concern #4: Too-Fast Development*
The concern that this vaccine was developed too quickly is one that I had before looking into this. In truth, mRNA-based therapies have been in studies for about 30 years (1990 study, 1995 study). It is true that this technology has never before been used as a vaccine, but there are lots of studies showing this mechanism works and is useful (2017 patent on the idea), especially used in cancer therapies (2015 study, 2016 study). Even other members of the coronavirus family have been being studied for years (2011 study, 2015 study), and other mRNA vaccines have been in development (2016 study, 2018 study). The reason development was so fast is the interconnected nature of science today. The previous studies provided the methods (which are usually the longest part of doing any experiment: figuring out how to do it right), and our DNA sequencing technology (think 23andMe) is fast and inexpensive compared to any other time in history (here’s the genome). Once we sequenced the viral DNA, we could compare it to thousands of other sequences available online to find the part which coded for a protein that was on the outside of the virus. Genetics is a quickly developing field because engineers optimize the tools scientists use & the scientists can then share their knowledge easily (this website has much of that shared scientific data, including the Sars-Cov2 genome). I am no longer concerned about the speed of development, personally.
*Addendum 4/8/21 – Studies are underway for both pregnant women and children under the age of 16. Pfizer’s March 31 report discusses the 100% prevention of COVID infection in the 1,131 adolescent participants who received the vaccine without any serious adverse effects. Their clinical trial on the vaccine in pregnant women has no published findings yet.
Concern #5: Mutating Virus
It is true that the virus has many different mutations even now, compared to when it was first discovered (you can see a map of the mutation tree here). Different strains are more common in different geographical areas than others. However, it has been observed that the spike protein which was chosen for the vaccines’ target is not in a frequently changing region of the genome (called a consensus sequence). This means that the antibodies we develop and the training the T cell receive should not be rendered useless if we encounter different versions of the virus.
Update: Yup, the mutations in the virus did get to the spike protein! This is why we see varying responses with various mutations. However, consistently the vaccinated populations have had lower risks of severe effects from COVID infections, even if they still contract the disease.
Concern #6: Long-term Effects & Allergies*
While long-term effects have, by definition, yet to be observed, I have little concern for long-term effects in this case. mRNA is quickly degraded by our cells and our immune system kills any cell that expresses non-self proteins. Since the mRNA cannot integrate into our DNA and the contents of the vaccine are all natural components of our bodies, the theoretical long-term risk is very low. However, just like with any vaccine, allergic reactions can still happen, and some have already been reported. If you have had serious allergic reactions to vaccines in the past, please consult your doctor before getting any vaccine, including these. I will be watching the weekly reports regarding the vaccine here, and the public is encouraged to report any adverse effects from vaccines here.
*Addendum 4/7/21 – Long-term effects of the virus should also be considered when weighing the benefits versus the risks of this vaccine. This study showed that a third of the patients followed for long-term effects of having COVID-19 were diagnosed with neurological or first-time psychiatric diagnoses within 6 months of recovering from COVID-19. While not everyone has terrible long-term effects from COVID, these are definitely a risk with natural infection.
Pfizer’s April 1 report looks closely at what effects have occurred in those who have been vaccinated for 6 months. While there were some COVID cases (about 9% of participants) in the immunized group, none of those immunized had severe COVID and none of them got the B.1.351 variant from South Africa. While this report is not technically a peer-reviewed journal article, I wanted to share the most up to date info we have. Pfizer says that they are preparing a publication which will be peer-reviewed soon.
Concern #7: Big Pharma
I have been asked the very good question, “How do we know that our available information has not been curated/canceled/payed off by those with a vested interest in the public not knowing the truth?” In essence, can we trust the data we see to be the whole picture? If I were to tell you the answer was absolutely, unreservedly yes, I would be either lying outright or just daydreaming because the truth is that we have no solid proof, either way. We have witnessed social media cancellation of dissident views and I will confess to you, friends, that I have this same concern. That is why I do my very best to look at a wide variety of sources, while still restricting myself to peer-reviewed articles or official reports. Is that enough to counter a large, invisible organization manipulating the data I see? Probably not. However, please let me remind you that the lack of proof against something is not equal to proof of that thing.
For instance, we all know that simply because we cannot disprove the existence of a jolly old man named Santa who goes around giving little kids toys on Christmas does not mean Santa therefore must exist. We cannot disprove his existence because we can’t be everywhere all at once. We could prove that he doesn’t live at the North Pole because we can go there and see no house, but we can’t prove that he doesn’t live anywhere. The same applies here. Just because I cannot disprove the theory that all data is curated by a malevolent “pharma,” does not mean that it is.
I would love to have hard proof that this is not happening, or definitive proof that it is. It is a fear of mine, as well. Are all of my time & efforts being wasted because I’m being brainwashed? That would be completely horrible and an extremely expensive folly. But I am called to do my best, not to know everything, and you are called to the same thing. We can only know what is for us to know and the rest we must lean on guidance from the Lord. While I think the best I can do is to study the available literature and learn from those experts who have literally devoted their lives to learning the truth about medicine and science, I know that it is possible that you will disagree with me. I would like to encourage you to lean in and seek the peace that surpasses understanding, regardless of your stance. And if your current stance does not hold that peace, seek His guidance as to if you should change your stance.
A more specific concern under Big Pharma is that this invisible, powerful group gains a lot of money from vaccines, in general. I am currently researching this, because I have been told by a professor whom I greatly respect that pharmaceutical companies do not usually break even on vaccines. He explained to me that it is the pills which treat medical conditions which earns them the big bucks, and the reason that former President Trump started “Operation Warp Speed” was to give the pharmaceutical companies incentive to participate in COVID vaccine research. Without those funds, my professor said, there would be no reason for those companies to invest into vaccines at all. Vaccine development is very expensive, and are often covered by insurance (now if you wanna go off on insurance companies as the maleficent being, that’s another story… plenty of evidence there). The pharmaceutical companies would do better financially providing a drug to treat COVID because a vaccine has a self-limiting demand (meaning as soon as everyone is vaccinated, they can’t sell any more doses). While I believe this professor who has been an allergy doctor for decades, I do not yet have sources to share with you on this topic.
General Concern: How do I know what to trust?
To this question, I say, “I’m right there with you.” This world is so full of information and misinformation that it is nearly impossible to curate our libraries well. People posting online with no credentials may seem to have a better grasp of their content than that expert you heard give directly opposing advice. There is no way for an untrained person to tell the difference between someone who does and does not know what they’re talking about unless that untrained person has a reliable source to lean on. How do we find that reliable source?
The approach I have chosen to take is one focused on prayer. When I see political information online which I have no method of verifying, that used to disquiet me substantially because I had no way of knowing if it was true. Now, I try to actively relinquish my “right” to know the truth by giving it to the Lord in prayer. He usually will provide me with a peace that allows me to move on. Other times He continues to prick my interest and I try to read many sources on the topic in order to come up with an average viewpoint. In the realm of science, He has given me a strong education background from which to understand much of the confusing news. I lean heavily on what my professors have taught me over the past few years in order to gauge if what I am reading makes sense. I understand that those without that level of background don’t have that security. My encouragement to you, if you are my brother or sister in Christ, would be to lean on Christians who do. Find someone with a good background in whatever is concerning you who is a brother or sister in Christ (or just that you can trust) and then ask them if they would be willing to help you understand.
The devil is actively seeking to separate us, scare us and lie to us. Let us as a Church take a stand against the fearmongering and help each other. So much of the misinformation which scares us today can easily be combated by a qualified Christian. Let us lean on each other. And as I mentioned earlier, if something is scaring or disquieting you which is within my realm of study, I would be more than happy to discuss that with you. If I do not know the answer, I will either seek out or direct you to those who do.
Every medical decision is a balance of risks and benefits, and this is no exception. As further data and questions arise, I will continue to update my thinking. I encourage you to do the same.
Final Question: Are you in line?
Yes! As a medical student, my school has been working on getting the vaccine for me and my peers. I have chosen to get it, even though I have already had COVID, for multiple reasons. There are studies showing that those who get the vaccine actually have a better immune response than those who developed immunity naturally (study), so it may still be important to get the vaccine even if I have developed antibodies. There are also reports of people getting COVID for a second time, and of people getting tested for antibodies and coming out empty. Natural infection of this virus may not induce our immune system to make the long-term memory defenses we need. While I fought off COVID with very little trouble the first time, this virus has been known to be worse the second time around. I have loved ones who are very vulnerable and I hope to be able to work in clinics soon, so I want to protect the people around me. I also want to be able to travel internationally this summer. I encourage every Christian to approach this decision with prayer, and I have done so. My husband and I feel that the Lord is leading me to get the vaccine when I can. I recognize fully that He may direct others down a different path, and encourage you to listen closely to His leading.
Summary
These vaccines are of a new type, which is concerning to many people. However, the real-world outcomes have been very safe & I see no reason to believe that this vaccine will have dangerous long-term effects. In fact, I think it will be a standard for others to follow and may make all future vaccinations more safe. As always, I encourage anyone who is worried to ask questions of those who have training in the area of concern.
Resources
10/11/21 – I wanted to add a space for me to share resources with you, even though I think most people already read this document & won’t see it. But the Institute for Functional Medicine has a great dashboard! And I love their vaccine data tables.