Covid Vaccination and Its Complications

Doctor drawing up Covid-19 vaccine from glass phial bottle and filling syringe injection for vaccination. Photo: The Star

It is always disheartening to learn that some people have developed side effects to any of the Covid vaccines, and my heart goes out to all these people, especially the young lady who developed the very rare but serious complication of Cerebral Venous Sinus Thrombosis (CVST) or blood clots in the brain. I wish her the very best on her road to recovery.

I write this piece as someone who was quite seriously ill with COVID-19 infection in March 2020 and as someone who since then, continues to treat acutely ill Covid patients in a UK hospital. In short, during my Covid illness, I felt 10 times worse than when I had malaria, and it was an illness I would not wish to have again.

I wish to provide some perspective on Covid Vaccination and this serious complication of CVST so that people can make informed choices when it comes to receiving the Covid vaccine. As we all know, COVID-19 is a serious infection, especially in the vulnerable population. But we also know that for many people, especially the young and healthy who acquire the COVID-19 virus, they only manifest minor symptoms and make a full recovery from it. But they are at risk of transmitting it to a more vulnerable relative they are in close contact with. A mild cough and a slight sore throat in a young person with mild Covid symptoms can be a death sentence to a vulnerable close contact. To date (October 2021), an estimated 4.8 million people worldwide have died as a result of being infected. This is the equivalent of 16 countries with a similar population size to Vanuatu. In patients who have recovered from Covid, most people will have an assortment of on-going symptoms, such as extreme tiredness, headaches, problems with concentration and breathlessness, for an extended period (the so-called ‘long covid syndrome’).

Our neighbours and fellow Pacific islanders in PNG and Fiji are in the midst of a public health emergency as the infection continues to sweep through their communities. Thanks to the excellent border control measures instigated by the Vanuatu Government Covid Task Force, Vanuatu has been kept Covid-free, and for this, they should be congratulated. However, despite all these efforts, it could be a matter of time before an undetected case slips through, and Vanuatu could be in the similar unenviable position as our Pacific neighbours if the population is not immune. Border control measures do not totally eliminate the risks of entry; they only mitigate them.

We know that getting vaccinated protects you from getting COVID-19. However, even if you are vaccinated, you might still get the illness but here is the thing: you will be less likely to suffer from a severe form of the illness, and you will be less likely to die from it. Please note that no vaccine can ever provide 100% protection against the disease it is meant to be preventing. The people we are currently seeing in hospital with COVID-19 (the UK 3rd wave) are those whose immunity is impaired for whatever reason or those who have not been vaccinated. The vaccine also reduces the risk of an infected person transmitting the virus to someone else. If that ‘someone else’ is your unvaccinated overweight diabetic 60-year-old father, he could be very seriously ill, or worse. It is estimated from UK data that 2 doses of the AstraZeneca vaccine is 92% effective in preventing hospitalisation due to Covid infection. Furthermore, deaths from COVID-19 infection is consistently lower for people who received 2 doses of the vaccine. There is therefore no argument that Covid vaccination works, and is the cornerstone in enabling the world to recover from the COVID-19 pandemic by reducing the risks of dying from COVID-19 infection, and by reducing its transmission in the community.

It is common to develop some side effects after any Covid vaccine. People may complain of a sore arm, a slight headache, a flu-like illness and feeling of tiredness, but the vast majority of these will disappear after a few days. One of the most serious complications is CVST, and I would like to make a few comments on this.

CVST is the development of blood clots in the blood vessels that drain the blood from the brain (the venous sinuses). It can occur in the general population (in the absence of Covid infection and without the covid vaccine) due to many reasons such as underlying blood disorders, dehydration, infections, head injury, pregnancy and medications such as some birth control pills. Thankfully this condition is extremely rare, occurring in around 2 people per 100,000 population per year. That is to say that, statistically, without covid infection or covid vaccination, 6 people in Vanuatu, mostly women between the ages of 18 to 45 will develop this condition every year. Patients may complain of headache, confusion, seizures, drowsiness, and some unfortunately will die if the condition is not recognised and treated.

We also know that having Covid infection increases the risks of developing blood clots in the body such as in the legs, in the lungs, in the abdomen and in the brain. I know from professional experience that a blood clot in the legs or the lungs of a covid patient is regarded as a normal part of the ‘covid illness’ spectrum so in some circumstances, patients are given the full treatment for such blood clots without having to confirm the presence of a clot with further test.

With regard to the serious condition of CVST, the data varies depending on which study is read, but the experts say that if you have COVID-19 infection, you are 14 times more likely to develop CVST than the non-Covid population. With regard to CVST in those who receive the vaccine, since April 2021, an increasing number of patients who had received the AstraZeneca (AZ) vaccine were noted to develop CVST. The estimates vary depending on which country’s data set is reviewed; Norway in April 2021 for example cited the highest case numbers of AZ-related CVST with 5 cases of CVST reported amongst 130,000 people who were vaccinated with the AZ vaccine, giving an incidence of CVST in the vaccinated group of 1 person out of 26,000 people who had the vaccine. (Remember that without Covid infection or Covid vaccination, 2 in 100,000 or 1 in 50,000 people will develop CVST per year). In contrast, in USA, 15 cases of AZ-related CVST were reported in 8 million people who had the AZ vaccine, giving an incidence of CVST of 1 in 533,000 vaccinated people. This is clearly less than the rate of CVST seen in the normal population although a lack of recognition and hence diagnosis, and under-reporting may account for this low number. There is no doubt that having the AZ vaccine therefore increases the risk of developing CVST, which is most commonly seen in the younger age group (< 40 years), and mostly occurring within the first month of having the first dose of the AZ vaccine. However, CVST thrombosis remains a rare complication of Covid vaccination – I know this is no comfort to the young lady who developed this, nor to her family who are supporting her through her recovery but each of us have to make an informed decision on whether or not we would have the vaccine. We have to do our own risks versus benefit assessments regarding the vaccine, and risks calculation around what is the likelihood of us getting Covid and suffering seriously with it, both in the acute stage of the illness and during the ‘long Covid’ phase.

So, the question is – should I have the vaccine? In countries where the rate of vaccination is low despite a high COVID-19 transmission rate, an increase number of unavoidable deaths from COVID-19 have been seen. In these areas of high transmission, the risks of dying or becoming seriously ill with Covid far outweigh the risks of having complications from the Covid vaccine for most age groups. CVST is a very serious condition but you can develop this when you have Covid infection as a complication of the infection; you can also develop this as a result of the AZ vaccine. However, you are far more likely to develop CVST when you have COVID-19 infection, than from having the AZ vaccine. My view is this: assuming I live in an area where there is a high transmission rate of Covid, I would choose to be vaccinated, and if I was under 40 years old, I would choose an alternative Vaccine to the AZ vaccine. There is limited data on blood clots with the Sinopharm vaccine and I am not aware of any reported cases of CVST after the Sinopharm vaccine in the literature.

But in Vanuatu at the moment, the rate of transmission of COVID-19 is virtually zero, due to the excellent work by all agencies involved in preventing COVID-19 from entering at our borders. If the vaccine has the potential of making recipients ill, and, given that there is no COVID-19 virus circulating in Vanuatu communities at present, and provided these border-control measures remain in place, there is an argument against the necessity of any vaccine at the moment. However, viruses do not recognise international borders; any border-control measures including ‘test and trace’ and quarantine are never going to be 100% effective against COVID-19; PCR swabs can return a negative result if the sampling technique is unreliable or the viral load at the time of sample collection is low, for example. It will only take a slight weakness in the border wall defences for the virus to enter, and in an unvaccinated, non-immune population, it would result in a major public health disaster and sadly, death to some. Sadly, this is what is happening in Fiji. Also, this infection is a ‘pandemic’ so combating it requires a concerted effort and cooperation of all countries. Measures to mitigate its spread have to be equitable in all countries – it is no use one country embracing the full vaccination programme whilst a neighbouring country has only vaccinated a fraction of its population, due to logistical problems, financial constraints, or personal choices. All countries must adopt a similar (high) level of vaccine coverage if the world-wide transmission is to be halted.

Logic tells us that if you have a low vaccination rate, you will have a high number of COVID-19 cases, if the virus takes a foothold in that country. This is exactly what is seen in the most-hard hit nations who had a low vaccination rate, such as India, Russia and Ukraine. Fiji currently has 52 % of its population fully vaccinated, so the virus is still raging on as half of the population is non-immune. Countries with a greater degree of success in controlling COVID-19 spread are those which rolled out the vaccine to a maximum when their level of transmission was low.

Here is some more data for you, courtesy of the WHO: From January 2020 to October 2021, Singapore (an island state) had 129,229 confirmed cases, with 172 deaths. Currently 81% of the Singaporean population is fully vaccinated. During the same period, Fiji had 51,535 confirmed cases with 652 deaths. Vaccine coverage in Fiji is currently only 52%. A rough calculation suggests that the death rate from Covid infection in Fiji is 10 times higher than that in Singapore. Whilst it is accepted that Singapore clearly has better healthcare facilities than Fiji which in part could account for this difference in death rate, there is no doubt that a better vaccine coverage in Singapore is a major contributory factor to this difference. Closer to home, in Vanuatu, it is estimated that only 8% of the population are doubly- vaccinated. What will happen if the virus manages to slip through our borders? What proportion of our population is vulnerable? Can our health service cope with the expected numbers that will need hospitalisation? Are we prepared to see similar death rates as they are currently seeing in Fiji?

The Vanuatu health authorities cannot force anyone to have a Covid vaccine – that would be an infringement of the individual’s right to make autonomous decisions for their own health and those that are legally under their charge. It is down to each individual to make their own decision with regard to receiving the Covid vaccine. But I think it would be useful to think about the following questions when making your decision:

1) How confident am I that the Border Control measures are going to stop COVID-19 from entering the country?

2) If I am confident that Vanuatu border control measures will prevent COVID-19 from entering the country, am I prepared to suffer any minor side effects of the vaccine (and take a risk with suffering from the very rare but more serious side effect of CVST), in the knowledge that I may not need this vaccine at all as I am confident that the virus will never enter the country?

3) If COVID-19 does enter the country, how likely am l to be seriously ill with it, given my medical history, my age, my weight? (main risks factors include old age, overweight, underlying medical problems,)

4) If COVID-19 does enter the country and I am seriously ill with it, what do I feel my chances of surviving are, considering my risk factors and my access to health care facilities?

5) If COVID-19 does enter the country and I am not vaccinated, can I afford to self-isolate and avoid any contact with potential virus carriers?

6) If COVID- 19 does enter the country and I choose not be vaccinated, and it is felt that I may have transmitted it to my vulnerable relatives, how would I feel?

7) Do I feel it is my moral duty to get vaccinated to increase vaccination coverage in the population to reduce viral transmission rates, hence reduce the rate of hospitalisation and death in the population at large, although I am young and fit and confident that even if I did not get vaccinated, I will only get some mild symptoms if I had the Covid infection?

In this piece I hoped that I have presented some thoughts to allow individuals to use to make an informed choice about receiving the Covid vaccine. I do not represent the government, I am just an individual who had to ask these questions before receiving my Covid vaccines.

Les Ala FRCP

Consultant Physician

Wales, UK

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