This was my fourth inauguration as a department chair. For each one, we’ve prepared for chaos and turmoil. The IEDs and the weapons that were found related to the Capitol Hill riots on January 6th certainly raised our level of concern and had me do more intense prep work than usual. I’m pleased that this past Wednesday was similar to the other three inaugurations with lower than normal patient volumes during the day (as I imagine people stayed home and watched the event) and then volume picked up a bit in the afternoon and evening. Fortunately, there were no dramatic events. We had great coordination and cooperation within the hospital and with Arlington Country Fire and Police.
There does appear to be some good news on the testing front from the emergency department. For the second week in a row, we saw a slight decline in the number of patients that tested positive in the emergency department. I am also seeing a slight decline in the positivity rate when I look at emergency department patients who present with symptoms that suggest COVID as well as all comers. Although the rate is not as low as it was prior to Thanksgiving, the number of positive tests and the positivity rate are better than 2 weeks ago. We had a lot of positive tests in December, nearly twice as many as we had during the spring peak. January is looking to be more in line with the spring peak which was much higher than June through November. Because so many of our patients are now coming in with a history of a positive test, these patients do not get retested so I always do try to balance out the number of positive tests with patients that we’re actually treating. In looking at the number of patients that we put on COVID isolation, that total is down a touch this week compared to the previous weeks. However, the number of patients being admitted is still in the same general ballpark as the last several weeks. Although the ER is trending in the right direction, the ICU team and the hospitalist team remain incredibly busy. These two services have cared for more than 2000 COVID patients over the last year. They have been pushed and stretched thin and just done an amazing job caring for all of their patients. The hospital inpatient COVID census remains high and is similar to last week. We know that hospitalizations and deaths peak a few weeks after cases increase in the community. But if ER volumes continue on their current trend, maybe we’ll see a decline in our hospital census and the amount of deaths over the next few weeks as well.
Although our data is not getting worse, the CDC is very concerned about the potential spread of the UK variant leading to another surge in March. You may recall that the mutations that cause the UK variant lead to increased transmission. This means more people will get infected with COVID. Although the variant does not lead to more severe illness, more people infected does lead to more hospitalizations and more total deaths. The mutant variant found in South Africa and Brazil, does look to be more aggressive and lead to more severe disease. Both of these variants are why public health officers say we need to be more vigilant in our masking and physical distancing efforts. These are the keystone mitigation strategies that reduce spread and we need to continue to practice them.
I received a lot of questions about the vaccine over the last month or so; below are my answers to the FAQs. There are always things that may be specific to an individual patient and these should be discussed with your doctor. The following is a big picture overview of the vaccine and should not replace discussions between you and your doctor.
1. What vaccine should I get question? The short answer is that you should get the first available vaccine regardless of who the manufacturer is. Both vaccines that are on the market have very similar efficacy and safety profiles. They also both work the same way. At this point, there is not enough vaccine availability to be picky and request one over the other. Even over the next couple of months when we expect 1 or 2 other vaccines to hit the market, it will likely still benefit you to get the first available vaccine.
2. Should I get the vaccine if I am pregnant or breast-feeding? The vaccine studies did not include pregnant or breast-feeding women. Therefore, there is no clear data proving that the vaccine is safe and effective. With that said, there are vaccines that are given safely in pregnancy and breast-feeding women. Given the potential complications of COVID, OB/GYN societies have supported vaccination for pregnant women who are at high risk of contracting COVID. (of course, many can argue that the community exposure/transmission is far outpacing the risk to front line workers so perhaps nearly everyone is at risk). I know many pregnant women who received the vaccine because they work in the hospital. Breast-feeding is interesting. Again, no studies. The vaccine does not contain live virus so the risks to the baby through breast milk are exceedingly low. In fact, maternal antibodies could theoretically get passed on to the baby and be protective. If you’re concerned, you can certainly build up a cache of breast milk ahead of time by pumping and then continue to pump and dump for a period of time. Both of these question should be discussed in detail with your OB/GYN and your child’s pediatrician prior to making a decision. My understanding is that the CDC is collecting information on pregnant women who get vaccinated (there is a check box during the registration process; there’s also a checkbox for pregnancy and nursing home patients when I order COVID tests that assist with data collection).
3. How bad are the side effects of the vaccine? Not bad enough not to get it. Keep in mind, the complications of COVID can be pretty bad so getting the vaccine is already a win. There are a decent percentage of people who are going to have fevers and chills and muscle aches and fatigue after the vaccination. My experience in talking to friends and watching a department full of doctors, nurses, and techs get the vaccine is that almost everyone had some degree of arm pain, like anyone would after any shot. Reactions were infrequent after the first vaccine but more common after the second vaccine. I know 1 or 2 people who had very high fevers and felt incredibly bad for about a day. I know a few others who had chills and muscle aches and fatigue. Most of us tried to schedule the day after the vaccine as a nonworking day though I am not aware of anyone who had to call out sick from work after the second dose if they were scheduled to work.
4. What if I am immunosuppressed? If you are immunosuppressed it is critical that you talk to your doctor. The concern being that if you are immunosuppressed, you may not be able to mount an appropriate antibody response and therefore not get benefit from the vaccine. However, being immunosuppressed may limit your ability to mount an appropriate antibody response to fight off the infection and that would put you at a higher risk for a poor outcome if you get COVID. There are some patients who are acutely immunosuppressed such as someone who is on steroids for a COPD exacerbation. In this case, it’s likely fair to delay vaccination until a few weeks after your steroids are completed and your immune system is back towards normal. For other patients who are undergoing chemotherapy, their doctor may recommend getting the vaccine when chemotherapy is over. Again, talk to your doctor about your specific condition and the timing of the vaccine.
5. How soon can I get the vaccine after I had COVID? The initial guidance from the CDC was to wait 90 days after you have had COVID. This was based on that most people who have had COVID develop antibodies and are unlikely to be reinfected in the first 90 days and therefore could get the vaccine when it is in better supply. What I am hearing now is that the vaccine is safe to get after you have had resolution of your COVID symptoms. This is probably about a month after you have been diagnosed for most people.
6. When do I become immune? The studies showed a decrease in symptomatic COVID infections in the vaccinated patient population compared to the control group about 12 days after the first dose of the vaccination, though immunity after 1 dose of vaccine has not been well studied. The vaccine was given FDA EUA as a 2-dose series, so I am hoping that continues as the standard. Immunity is significantly increased approximately 1-2 weeks after the second dose.
7. How long will immunity last? The short answer is we do not know yet. The disease and the vaccine have not been around long enough for us to test how long vaccinations last. Immunity is expected to last a minimum 8 to 12 months. It’s possible it will last longer. We know from the multidose vaccinations that children get, it is possible to get lifelong immunity.
8. Why do we have to wear masks after vaccination? For starters, while the vaccination appears to reduce infections by about 95%, a small percentage of vaccinated people will get symptomatic COVID. It’s not 100% protective. It is possible that vaccinated people will have enough antibodies to prevent becoming asymptomatic carriers, but this was not tested during the vaccination studies and there is just no data yet showing whether or not vaccinated people can be asymptomatic carriers. The vaccine clearly reduces the likelihood of getting COVID and essentially eliminates the risk of having severe disease. There is an interesting study that just came out of Israel looking at 102 healthcare workers after they were vaccinated and then had antibody measurements done. All but two people had an excellent antibody response, so much so that the researchers believe that vaccinated people would not be asymptomatic carriers because the virus would never be able to replicate. This is different than testing people to see if they are carriers, though a study done on monkeys with similar antibody response showed that the monkeys were not carriers. These same researchers also found that the amount of antibodies was 20x higher one week after the second dose than after the first dose. So while masks need to be worn now, all of this together is why masks likely won’t need to be worn after there is herd immunity. There’s one other point to consider about wearing masks post vaccination. People who have been vaccinated to do not walk around with a glow or any special way for one to know who is and who isn’t vaccinated. Therefore, for the time being, it is more important, particularly for healthcare workers, to continue to wear masks to set an example of ways that we can protect each other from transmission. Everyone wearing a mask for now will reduce transmission and remind people of the importance of to get vaccinated.
9. When will herd immunity be reached? The general consensus is that we will need approximately 75% of the population to be vaccinated (or have antibodies from diseases) before we reach herd immunity. The 95% vaccine effectiveness is critical and is on par with measles and chickenpox vaccines. I’ve never seen a case of measles and I see chicken pox (not shingles which is reactivation of the chicken pox virus) a couple of times a year. While the vaccine is likely to prevent you as an individual from getting COVID (and certainly seems to prevent the risk of a severe infection or death), over time, having everyone vaccinated will lead to herd immunity and the elimination of the virus. In order for the virus to spread, it needs to find new hosts (people) who can give it at home. As large amounts of the population become vaccinated, there will be less available hosts for the virus which reduces replication/reproduction and spread to others, and the virus will die out.
10. When will I be able to get my vaccine? There is a disconnect between how much vaccine has apparently been delivered to states and how much has been administered. There is also a clear shortage of available vaccine to be delivered to states as states and local vaccination centers cannot get enough to meet their demand. While I am optimistic that supplies will be more available in the upcoming weeks and months, I encourage people to not jump the line. I know there are some loopholes that people take advantage of but if we can get the elderly and the medically at risk vaccinated, we will see space open up in the hospitals and the amount of people dying will decline. I’m willing to bet that vaccinations will be much more available to everyone during the spring.
11. Will the vaccine be effective about the new mutant strains? The vaccine helps the body respond to the spike protein on the virus. It’s very likely that the vaccine will be effective against the new strains but there’s not enough data yet be say that definitively for all new strains. We know that viruses mutate over time, so it remains critical that we do everything possible to get the virus under control as soon as possible to help reduce the likelihood of future mutations.
12. Should I still get the vaccine if I’m allergic to a lot of medications? The likelihood of an allergic reaction to the vaccine is very low, but not zero. With that said, the CDC has very clear guidelines about who should avoid the vaccine and how long people at risk of allergic reaction should be monitored after receiving the vaccine. A previous history of food or medication allergies is not a reason to avoid the vaccine. However, you will likely require a little longer monitoring afterwards. If you have a history of severe allergic reaction/anaphylaxis to another vaccine or an injectable therapy, you should have a discussion with your doctor to assess your risk. If you proceed, you’ll need a 30-minute period of observation after vaccination. Finally, the CDC only lists a history of severe allergic reaction to any component of a mRNA COVID 19 vaccine as an absolute reason not to get vaccinated. Please talk to you doctor and allergist to make your decision but most people with medication allergies will be able to get vaccinated.
13. When will children be able to get the vaccine? The vaccine is not approved for kids <16 years old. That age group was not studied for safety and efficacy, but studies are in the works and hopefully we’ll have the data by summer, if not sooner. The Pfizer arm for 12-15 year old age group is full enrolled so possible results in 3 months. Getting teachers and school employees vaccinated before schools reopen, I think, is really important. Getting kids vaccinated would be ideal but is not currently a requirement prior to opening schools. I have a 15-year-old and hope he can get vaccinated soon.
Science matters. Wear a mask. Practice physical distancing.
PS The pic is of our favorite family member and hopefully makes you smile.