Letter for February 24, 2022

Putin sucks. New pneumonia shots. The best side to sleep on. The best source of Covid treatment updates. The Danish are good at snuggling, bad at Omicron waves. Dealing with bullies.

I’ll keep this letter on topic, but I have to acknowledge the sadness and anger most of us are feeling towards the Russian leadership - authoritarian, revisionist, duplicitous, and malignant force that it is. From doping their 15 year-old girls competing in the Olympics, to murdering journalists and dissenters, to starting a war in Ukraine, to opening a new chapter in the history of human warfare - it all combines to make me sick. The problems faced by the Earth and its peoples - a global pandemic, climate disaster, the 6th mass extinction in progress - it would all take cooperative, enlightened, peaceful leadership to fix.

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Alive [longevity and an ounce of prevention]

* Pneumococcal vaccine updates. Most people over age 65 and those with chronic medical issues like asthma, diabetes, and kidney disease have already received a dose of Pneumovax, and maybe Prevnar. These vaccines help to reduce infections caused by the bacterium Streptococcus pneumoniae, including pneumonia and other invasive infections. The guidelines for vaccination are changing for the 4th time in 10 years, as Prevnar-13 gets an upgrade to Prevnar-20.

Prevnar 20 (abbreviated PCV-20) covers an additional 7 types of Streptococcus pneumoniae. This broader coverage will hopefully prevent more infections.

CDC estimates that there are about 30,000 invasive pneumococcal cases in the U.S. each year, including meningitis and blood infections, leading to around 3,000 deaths. Vaccination reduces this risk of invasive disease by about 70%.

In terms of streptococcal pneumonia, there are around 100,000 hospitalizations per year. The current pneumonia vaccines prevent something like 75% of those hospitalizations, and reduce overall pneumonia infection rates by about 50%.

By getting Prevnar-20, it is expected these numbers will improve as more serotypes are covered. So this is what we are doing going forward, including in my office:

For all older adults (age, ≥65) and to all adults who are at elevated risk for pneumococcal disease because of immunocompromise or certain medical problems:

• For those who are getting their first pneumonia vaccination, one shot of PCV-20 is recommended.

• For those who have already received Pneumovax in the past, an optional booster with PCV-20 can be given.

There is also another new vaccine called Vaxneuvance (PCV-15), which covers 2 additional S. pneumoniae strains, but will find less use in the new guidelines and I won’t bore you with those nuances. There are other special situations, but the above addresses the vast majority of questions we will be receiving.¹, ², ³, ⁴, ⁵, ⁶, ⁷

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Well [ideas and studies that promote better health]

If you had to guess whether it is better to sleep on your right side, left side, or on your back to reduce gastroesophageal reflux symptoms… which would you say?

Women who have been pregnant might already know this answer, too.

Although the average number of nocturnal reflux episodes was similar in the three groups, acid clearance from the esophagus occurred significantly more quickly when patients were on their left side (median time, 35 seconds) compared with supine and right-sided positioning (76 and 90 seconds, respectively).⁸

The anatomy of the esophagus and stomach makes lying on one’s left side a better downhill gradient. The study did not include propping oneself up with pillows or elevating the head of the bed, which is often recommended for conditions like hiatal hernia.

Lying on the left side while sleeping also promotes better blood flow in pregnant women, as the enlarged uterus presses less on vital organs, veins, and the inferior vena cava as it returns blood to the heart.

Do not try this sleeping position at home.

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Aware [commentary on key news]

* I am frequently asked about treatments for Covid, and there is certainly a great amount of misinformation out there about hydroxychloroquine, ivermectin, and bleach. One of the best repositories of up to date, scientifically rigorous answers can be found at the NIH (National Institutes of Health) COVID-19 Treatment Guidelines website.

You can see how hard scientists, researchers, data crunchers, epidemiologists, and physicians are working to figure this out… and to separate the wheat from the chaff, the effective treatments from the snake oil. Take a couple days to review this, or just trust your local family doc who is trying to practice mainstream medicine.

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* Quick pandemic consideration. Denmark has one of the world’s highest immunization and booster rates - much higher than the U.S. So in early February, despite the Omicron wave, they decided to get rid of almost all public health mitigation measures. Since that time, rates of infections, hospitalizations, and now deaths have skyrocketed:

I think this shows that while vaccination is very important, if we try to go back to the 2019 rules of living and simply rely on our shots and prior infections, in the middle of a wave - it’s going to be a mess. We have to ride out the waves, keep our guards up when rates are high, and keep using the tools we have learned these terrible two years. Rates here in the U.S. are looking much better, and I’m hopeful for a good Spring. But dropping everything and pretending the pandemic is all done will invite the graphs above to repeat here.

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Happy [in the pursuit of contentment]

I’m having a hard time with the Happy theme for this letter, honestly.  The Olympics felt pretty flat. The whole Russia crisis. The weather is a cold, wet mess as I type this.

How about making some tea, putting on your slippers or wool socks, and reading a book in bed tonight? Start a cozy fire, or put that fake fireplace video on Netflix. That’s all I can advise for now. Denmark has never restricted hygge⁹, and I don’t think any public health authorities would challenge this behavior:

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Human [resisting trends that diminish us]

Much has been written about the numerous physical symptoms that Covid can manifest, but the disease is also quite adept at demoralizing us in numerous ways. I spoke today with a woman who did everything right for the past two years. She got vaccinated, boosted, wore a mask, distanced, and sacrificed seeing her family during holiday peaks. She let her guard down to travel and visit freely for one weekend with vaccinated family that she had otherwise avoided for two years. Incredibly, she developed symptoms, tested positive, and is pretty devastated that she unwittingly exposed some of her family’s most vulnerable members.

She will almost certainly be fine, and she knows this. What worries her most is the exposure of her more vulnerable family members. She tried harder than many others who have not gotten sick. But the tears flowed from a place of emotional exhaustion, from the guilt of trying to be normal for a weekend, and from a kind of shame we feel when contaminated by contagion.

Maybe it would help to think of Covid as a bully. Psychologists encourage bullied people to embrace the position of “target" rather than “victim.”¹⁰

The victim handles mistreatment privately, with shame and feelings of inadequacy. The target reaches out to someone who cares, avoids social isolation, and asks for help.

The victim internalizes misfortune as something she deserves. The target places the blame on the aggressor.

The victim believes he should punish himself. The target knows it’s not his fault, and instead boosts his care of self and cultivates resilience.

And finally, the victim feels powerless to resist mistreatment, and passively expects more. The target stays engaged, trying different approaches and strategies to outmaneuver the foe.

Viruses do not have the agency or free will to be actual bullies - but the physical and mental harm they have brought to civilization has certainly felt personal and cruel. Perhaps we can approach this disease and pandemic as targets - reaching out to others for help when we are spent, knowing that we deserve better in our short lives, boosting our self compassion and self care, and staying the course in a long conflict, empowered by the tools we know work against this enemy.

Also remember that bullies hate needles… so fortify yourself with a booster, too, if you haven’t.

And just maybe these notions apply to authoritarian bullies armed with nuclear weapons, too. Godspeed, democracies of the world.

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1. https://www.jwatch.org/na54651/2022/02/22/new-recommendations-pneumococcal-vaccination-adults

2. https://www.cdc.gov/mmwr/volumes/71/wr/mm7104a1.htm

3. https://www.cdc.gov/vaccines/vpd/pneumo/hcp/who-when-to-vaccinate.html

4. https://www.medscape.com/viewarticle/968119?src=par_cdc_stm_mscpedt?&faf=1#vp_1

5. https://www.jwatch.org/na54651/2022/02/22/new-recommendations-pneumococcal-vaccination-adults

6. https://www.pfizer.com/news/press-release/press-release-detail/a_study_analyzing_observational_data_shows_real_world_effectiveness_of_prevnar_13_in_adults_age_65-0

7. https://www.cdc.gov/vaccines/vpd/pneumo/hcp/about-vaccine.html

8. https://journals.lww.com/ajg/Fulltext/2022/02000/Associations_Between_Sleep_Position_and_Nocturnal.28.aspx

9. https://www.newyorker.com/culture/culture-desk/the-year-of-hygge-the-danish-obsession-with-getting-cozy

10. https://www.psychologytoday.com/us/blog/surviving-your-childs-adolescence/201309/being-target-or-victim-adolescent-bullying