Navigating COVID-19: Vaccines, Variants, Vigilance

Have questions concerning COVID-19 and vaccine options? Listen to the Vera Whole Health webinar with Bruce Heller, MD as he informs about different vaccine options, virus variants and how to stay vigilant in the fight against COVID-19.


Webinar Transcript

Jenn Roberts:

Welcome to the Vera Health COVID-19 Overview webinar. I'm Jenn Roberts, based out of Houston, Texas and your host today. I'm joined by Dr. Bruce Heller, who's presenting out of California as we explore the current state of COVID-19.

A couple of housekeeping rules. We have a really large group today and people from across the country with some internet connectivity issues. So, to keep the bandwidth down, we've muted all the participants, but feel free to send your questions through the Q&A function or the chat throughout the presentation. Dr. Heller, you may begin.

Dr. Bruce Heller:

Thank you, Jenn, I appreciate having the opportunity to speak to everybody about this important and timely topic. What I'd like to do today is talk about COVID-19. I'm going to give you an overview of the virus itself. We'll talk about general preventive measures, and then we'll talk in great detail about the vaccinations against COVID-19. I hope everybody's safe out there. I know there's some extreme weather across the United States. Without further ado, we'll get started. 

What is COVID-19?

COVID-19 is actually the disease caused by a particular virus called SARS-CoV-2, which is a coronavirus. The coronaviruses are a family of viruses that are found not only in humans, but also in animals. We know that they're found in some exotic animals, we think that this particular virus made the jump from bats to humans, but they're also found in common animals such as chickens, pigs, ducks, et cetera. 

In 2019, the SARS-CoV-2 virus made the jump from some animal reservoir into humans, and started causing the COVID-19 disease. Now, some characteristics of coronaviruses are that some of them cause very mild illness that can be responsible for the common cold, but they can also be responsible for epidemics, such as SARS, and MERS that you might have heard about in the past. 

One thing that's interesting about coronaviruses is that mutations are common, and they are expected. For instance, the SARS-CoV-2 virus shares about 80% of its genetic code with the original SARS that caused an epidemic in 2002.

How do we get sick from this virus?

Like all respiratory viruses, there's direct person-to-person respiratory transmission. These are typically the respiratory droplets that might be found in coughing, sneezing, talking, et cetera. But what's interesting and maybe a little bit different about this particular virus is that there's also airborne transmission, so that lighter aerosol type particles can stay in the air for a long time. 

Although there can be direct person-to-person, one person to one person transmission, there can also be one person to many transmission through this aerosol route, and that's how we can have super spreader events. There are also possible transmission routes through contaminated surfaces, although we think that this is potentially a little bit less of an important route of transmission.

Then in terms of when we get infected, you can get exposed to the virus infected, you're particularly contagious if you have symptoms at the beginning of your symptoms, when you have the most amount of virus in your body, and then there's a recovery phase.

Now, with this particular virus, asymptomatic spread is actually very important, and we don't see that very much in other respiratory viruses, and it's one of the reasons why this particular virus has been so deadly and difficult to contain. But symptoms can range from the most common symptoms that we've heard about such as fever and chills, cough, body aches, shortness of breath. In particular, this loss of taste and smell is not common with other respiratory viruses either.

This is something that when people have, we have a higher suspicion that they might have this particular virus. Then other symptoms might be nausea, vomiting, diarrhea, and these can range all the way up to very severe symptoms where you might have pneumonia, and multi-organ failure, hospitalization and death. This is really a bad player.

How will you know if you have this infection?

Well, there are multiple different testing options available. Probably the most accurate is a nucleic acid amplification test. What this does is it really detects a piece of the actual virus's, DNA or genome. This is a very accurate test. There are rapid options available. But this is the test that typically takes between one and four days to return.

There's also an antigen test, which is more commonly used as a rapid option. This is not as direct of a test, this actually detects proteins that the virus may have made. It's a little bit less accurate. Finally, there are antibody tests that can measure your immune system's antibodies to this virus, and it can tell us whether or not you had a possible past infection. This is not currently recommended, and it's not really used very much in clinical medicine. 

The question is, who to test and when to test. Those people who have classic symptoms, we might want to find out whether or not that person has the virus, and then people who have had close contact with those who have the virus, and then also in institutional setting, like those who have traveled might be in large gatherings, possibly in colleges or work settings. 

What's important about this is that although there are different testing options, we do want to know what your clinical scenario is, so we can pick the right test at the right time. Early in the course of this disease, or if someone is asymptomatic, we might need to wait a certain amount of time to test somebody, as opposed to somebody who is currently acutely ill with symptoms. What we do know about testing is that over time, testing has gotten better, it's been more accessible, and it's easier to perform. 

Remember, a year ago when we first started testing, people were getting these very invasive nasal pharyngeal swabs that went all the way back in their nose and felt like a brain biopsy. But now, they're much easier to perform, we can do tests on the front part of the nose, sometimes the throat, or even through saliva.

Remember, routine antibody testing is not currently used very much in clinical care. In terms of our Vera Health care centers, you might be offered drive through testing, testing that can be taken home, maybe with a saliva test, or done in the clinic. The big picture here is, please contact your provider so we know what your clinical scenario is, and we can decide what is the best test, and when is the best time to do it.

Where are we now with COVID-19?

Now, I'd like to talk a little bit about where we are now with this virus. This virus is really a bad player for a number of reasons. One, is that it's novel. What that means is that it's new. Our immune systems have no antibodies to this virus. So, it had the opportunity to spread like wildfire without any natural defenses. The other thing is that it's a highly infectious virus. You don't need much of the virus to cause an infection. 

The third thing that's important is that there's very high degree of asymptomatic spread. We think that up to 40% of the spread and transmission of this virus is from people who have no symptoms, and that makes it very difficult for us to know who to test and who to isolate to contain the virus. This was not the case, for instance, with the original SARS outbreak or with MERS, where people were very ill, and it was easy to know who was sick and that we could easily contain that virus. So asymptomatic spread is a big player here. Then finally, it is a deadly virus so that, people can have severe symptoms and then have bad outcomes.

Now, in terms of numbers in the United States, we currently have... These numbers are from last week, so they're higher now but we have over 28 million cases in the United States, and almost half a million deaths. In terms of the global population, the United States has about 4% of the population, but we have 25% of the total COVID cases and about 25% global deaths. This is really a bad player.

Then the other thing that has the potential to make this worse is that there are new variants, and mutations that are coming on board. Some of these we know are more infectious than the original SARS-CoV-2 virus, and they also may be more deadly. We know this is a bad player, it's causing untold human suffering, and also, from an economic standpoint, this has really been a step backwards, not only for us in the United States, but all over the world. So, we really need to find some ways to stop this from spreading.

What are some general safety measures?

First of all, we really want to use typical public health measures to decrease person-to-person spread, and that's going to be done through masking, hand washing and physical distancing. These are known and proven measures that have been used in public health for many, many years. In fact, even in the 1918, over 100 years ago, Spanish flu epidemic, some of these were techniques that were used then to try to contain the virus. 

The other thing is to decrease our risk factors for transmission, is that we want to limit our time with people. We do know that spending more than 15 minutes in close proximity to a person puts us at higher risk. Gathering outdoors where the virus doesn't have as good a chance to settle in our respiratory tracks, and cleaning surfaces so that we don't transmit the virus that way.

But finally, we have a potent new technique to help decrease the spread of this virus, and that's the COVID-19 vaccines. We're going to talk a little bit about the vaccines in general, and then we'll talk in more detail about the particular vaccines.

How do vaccines keep people safe?

The first way is that they prevent infections. A good vaccine will create an immune response so that your body makes antibodies or defense against getting infected in the first place. The second thing is, if a person is going to get infected with the virus anyway, that it would prevent disease. 

This is true of most vaccines that we have already been using for decades. Even if you were to get sick with say, influenza, or pertussis, the disease that you actually manifest is less severe if you've had the vaccine, than if you haven't. Then finally, we hope it prevents transmission of the virus. This is important for two reasons. One is, you can decrease prevention, one-to-one from, say yourself to a family member. But over time, it also helps to prevent transmission in communities through herd immunity. 

Herd immunity is when a certain threshold of a population is vaccinated so that even though a virus or other pathogen can be introduced into that community, it doesn't have a chance to spread like wildfire, like we've seen in this epidemic.

How was the vaccine developed?

I'd like to talk a little bit about how this vaccine and vaccines in general were developed, so that we have confidence that this vaccine is safe. In the four phases of clinical trials, our first phase is where we really are just interested in whether or not the vaccine is safe.

We have a vaccine candidate that we might think is going to be helpful from either lab studies, or from animal studies. You may have heard the adage first, do no harm. This is really what we're looking at in phase one is we want to make sure that the vaccine doesn't hurt anybody. The immune response and whether or not it's preventive against a particular infection is not very important at this stage. We're using really, a very small number of healthy volunteers.

In the second stage, we use several hundred volunteers, and what we want to see is are there common short term side effects? Does your body actually make an immune response, and does the vaccine seem to be preventive? If all of these things are met, we move into phase three, and this was really the meat and potatoes of any clinical trial, where we're looking at thousands of volunteers to see whether or not the vaccine is actually preventive. 

The way we do that is that we give some people the actual vaccine, and others receive just a placebo. Then we see how many people in the placebo group got sick, and how many people in the vaccine group got sick, and then we can compare. If all these are met, the vaccine is approved, and then we continue to look at its safety, and potentially other benefits, and also potential risks and continue to collect long term data.

How does this vaccine work?

Now, what I'd like to do is talk in more detail about these particular vaccines. You may have heard that these are mRNA, or messenger RNA vaccines. Well, what is that? Well, we're going to get into a little bit of basic science here, now. mRNA is a genetic material that contains instructions for making proteins. All living cells have mRNA, and it's just the way that we help to take the genetic alphabet and make sense of it, and then make proteins that we need for life. 

Now, in this particular case, the vaccine injects a little piece of mRNA that codes for these spike proteins, and all coronaviruses have a number of these spike proteins on their surface, and that's what gives it a crown or a corona and hence their name. This harmless piece of mRNA is injected into our bodies, and then it codes for a little piece of the spike protein, which in and of itself does not cause an infection or any harm. But what it does do is it triggers your immune system to make antibodies.

Those antibodies set up a defense mechanism, which do two things. One is that they protect us from getting an infection in the first place, and then another part of the immune system actually directly destroys the virus particles, okay?

How were they developed so quickly?

I also want to talk about how these mRNA vaccines were developed so quickly, because we have heard in the past that vaccines take years or even decades to be developed, and there were a number of reasons why these particular vaccines were developed so quickly. One is that mRNA is actually very easy to work with, and these vaccines in general are faster to produce than traditional vaccines. 

Last year, actually, in January of 2020, we were able to unlock the genome of the SARS-CoV-2 virus, and literally within days, the mRNA to create the spike protein was discovered. This happened very, very quickly. Then within weeks, they started to develop candidates for the vaccine.

Part of the reason for that is that the basic technology for these mRNA vaccines had already been developed for other viruses such as Ebola, influenza, Zika, SARS, RSV, and others. Then, the FDA approved Operation Warp Speed, which helped us to prioritize this happening in the field, which allowed researchers to use existing clinical trial networks to conduct COVID-19 trials. We didn't have to recruit new volunteers just from the general public. If people were part of other trials, we could then ask them if they wanted to be part of the COVID-19 vaccination trials. 

Then finally, something that it was also new, is that manufacturing was started while the clinical trials were still underway. As soon as we saw that the vaccines were safe, and probably effective, the components for the vaccines, and the vaccines themselves started manufacturing, so that when emergency use authorization was given, they were ready, literally millions of doses available to be shipped. So, we didn't have to wait until authorization and then start manufacturing. All of these are important reasons why the vaccine was developed so quickly.

What about safety?

I want to emphasize that all of the COVID-19 vaccines are being held to the same safety standards as all other vaccines, and no shortcuts were taken. All the phases of the clinical trials and all other safety mechanisms were followed. Then in terms of the specifics, we now have two vaccines that are currently available in the United States. One is the Pfizer/BioNTech vaccine and the other is Moderna vaccine, and these are highly, highly effective. They've been shown to be between 94% and 95% effective at reducing the risk of a COVID infection. 

These numbers are really high. Typical vaccine numbers, and what we were shooting for, what scientists were hoping for at the beginning of this are somewhere between 50% and 70% effective. The fact that these are 95% effective at decreasing any infection of COVID-19 is remarkable.

Now, these have some similarities, both are mRNA vaccines, they're both on a two dose schedule. Pfizer, 21 days between vaccines, Moderna, 28 days between vaccines. The other thing is that these were tested in a diverse adult population, including the people who are at highest risk for having complications of COVID-19. That includes the elderly, and underserved minorities.

Now, in addition to being 95% effective at decreasing the risk of a COVID infection, these have both been shown 100% effective at preventing hospitalization and death from COVID-19. I want everyone to just think about that number. This means that no one who has been fully vaccinated has ended up in hospital or who has died from this infection. This is an infection that is causing about 3,000 deaths a day in the United States. So, this is really remarkable.

How were the trials done for these vaccines?

Then I want to talk just a little bit about the trials that were done for these two vaccines. In the case of Pfizer, over 40,000 volunteers were enrolled.

In the case of Moderna, 30,000 were enrolled over a diverse geographic range, and 30% or more were from typically underserved minorities. This is important for a number of reasons. One is that these groups of people suffer complications of COVID-19 at higher rates than our general population. Because of our history, they may have some distrust of the medical establishment. So, it was very important for us to know that these were effective in the population that needed them the most, and who might want to have increased confidence in the vaccine. 

That is true also of the elderly. We do know that COVID-19 is more serious in the elderly. These were tested over a wide range of ages. Then in terms of ingredients, both of these vaccines contain spike protein mRNA, and these are encapsulated in a lipid capsule so that they can get into our bodies, and then there are other ingredients to keep it stable. There are no preservatives, so there's no thimerosal or anything else like that. The way these are being preserved is with very cold temperatures.

Are there any contraindications to getting the vaccine?

If you've ever had a severe allergic reaction to any mRNA vaccination, or to any of its ingredients, in particular PEG, which is a polyethylene glycol or its derivatives, you would not get the vaccine. You would know if you have an allergy to PEG if you've had any chemotherapeutic agents or other medicines that might contain that ingredient.

If you have a food or medication related allergy, these are not contraindications to getting the vaccine. Then, in addition to the normal safety mechanisms that we have in place, there's a new safety mechanism called V-safe, and this is a text based monitoring system that you can have the opportunity to join when you get the vaccine.

Now, in terms of getting these mRNA vaccines, we do know that some people actually get some side effects, and the most common is to get pain at the injection site. But you can also get a whole host of other systemic symptoms. For instance, body aches, fatigue, headache, fever, chills, and these are most common after the second injection. That's because the first injection is really a primer to get your immune system ready. But then when you get the second booster shot, it really is like a booster rocket that's ramping up your immune system. 

So, some people can have some of these uncomfortable side effects. These side effects are typically short lived. So, on the order of hours to days. Not everyone has them, and they can be easily treated if you decide to do so with over the counter medications such as Tylenol, or ibuprofen. Allergic reactions are very, very rare, and we will monitor everyone for at least 15 minutes after getting the injection. 

I do want to emphasize that even if you've had unpleasant side effects from the first injection, to please get the booster shot. The reason for that is that you only have partial immunity after the first shot, so you really want to get fully immunized. That happens about two weeks after the second shot. 

Where are we with the vaccines, currently?

These numbers have actually grown since last week. We've had over 70 million shots distributed across the United States, and over 55 million shots have been administered.

This is great news, because at the current pace, by June, 50% of our population will have had at least one shot, 70% by September will have had at least one shot, and by November, 90% of our population at the current pace will be at least partially vaccinated. 

This is going to help us determine when we can get back to normal. Now, there is a new vaccination that's potentially online, and that's the Johnson and Johnson vaccine, and that's going to be an important game changer in terms of these numbers, because that is just a single shot. We might be able to reach numbers where we have close to herd immunity sooner than those projections. So, let's hope we can have a semi-normal Thanksgiving this year.

In terms of the Johnson and Johnson shot, it has been applied for emergency use authorization to the FDA and we'll probably know by the beginning of March whether it gets approved. It's been shown to be highly effective at preventing disease, just like the other vaccinations. It's 85% effective at preventing serious COVID infection. In fact, like the other vaccines, not one person who has gotten this vaccine has been hospitalized or died from COVID-19. These are remarkable numbers. It uses a different mechanism. But like the other vaccines, it still creates a harmless spike protein to initiate the body's immune response. 

Who should get the vaccine, how and when?

Currently, as you may have all heard, there are some federal guidelines as to who can get vaccinated. The reason for that is that really the demand for this vaccine outstrips supply. It's a resource that is in short supply. We want to be fair to give the vaccine to the people who might have either the highest risk of getting the vaccine, or the highest risk of getting the infection, or having complications or death from the infection. 

That being said, each state may have different guidelines based on their supply and demand. So, please check with your state to determine what's available to you, and when. In terms of our Vera centers, we've already started administering the vaccine in Arizona and Alaska, and we're working closely with other states such as Washington, California, Nevada, et cetera, to see when we can get the vaccine and start administering it.

That really gives you an overview of the vaccines. In general, please keep in touch with your health care provider to figure out when and where you can get the vaccine. But now I'd like to answer maybe some common questions, and those who have special concerns about the COVID-19 vaccine. And, in particular, those who have common chronic conditions such as hypertension, diabetes, chronic kidney disease, cardiovascular or respiratory conditions, absolutely those people should get vaccinated. The reason why is that we know that those people are at higher risk for complications and death of COVID-19. So, please get your vaccines if you have any of these conditions.

Is this safe in pregnancy and breastfeeding?

The answer is yes. Even though these particular initial trials weren't done on pregnant women, there were women who got pregnant during the trials, and had healthy pregnancies and deliveries. Currently, this is being tested, in particular for pregnant women. 

In terms of breastfeeding, we do know that women who have gotten a vaccine and have antibodies to COVID-19 can pass those protective antibodies to their breastfeeding infant. There hasn't been any evidence that the mRNA itself or the spike protein from the vaccination gets into breast milk. But there's no indication that, that would be harmful, anyway. Those components tend to break down within days to weeks.

What about other immune related conditions, such as HIV/AIDS?

Maybe you have an autoimmune condition and are taking immune modulation drugs, same thing with transplant recipients, and Guillain-Barre, none of these are contraindicated for getting the vaccine, and of course, these are, again, at higher risk of potential complications from COVID-19. So, we really want you to be protected. Then if you have other conditions that are particular to you or your family, and you're not sure, please check with your provider.

What about children?

Currently, the Pfizer vaccine is approved for those over the age of 16, and Moderna, and Johnson and Johnson, if it's approved will be for ages 18 and over. Currently, studies are underway in children 12 and older.

What if you've already had a COVID-19 infection, should you get the shot?

You should and for a couple of different reasons. One is that we don't know how long natural immunity lasts. We know that it probably lasts for at least 90 days, but the other thing is if you got the vaccine maybe a number of months ago, you might not have natural immunity to the new viral mutants that are known to be coming online. We do know that the vaccinations do give at least partial protection against those mutations.

Will the vaccine give me COVID?

No, remember, the vaccine is only giving you a little piece of mRNA, which is then going to code for a harmless piece of the spike protein that then causes an immune response. So, you can't get COVID and you can't get a positive COVID test from the vaccine. That being said, because there are so many people who have an asymptomatic infection, you may actually have the COVID virus inside you on the day that you get vaccinated, and particularly after the first shot, you're not going to have full immunity, so you might still get infected in the days following your vaccination. You can still get infected between doses and even after the second dose. That is a way that you can have COVID and get symptoms of COVID and have a positive test, but it will not be from the vaccine.

Then how long will the vaccine protect me from COVID-19?

We're not sure yet, these studies are still being done to evaluate this. But we know that it's at least for many months, because the vaccine trials were started maybe in the middle of last year. We'll continue to evaluate this.

Then will the vaccine protect me against new variants?

Well, we know, at least for now that they are fully protective against some of the variants, and at least partially protective against some of the other variants. The other thing that might happen is, we do know that coronaviruses tend to mutate over time. Scientists were aware of this even before the vaccines were developed, and this may be the case where we might need booster shots in the future with a different piece of mRNA that covers the new mutations.

Now, who shouldn't get the vaccine?

Well, again, those with a known allergy to any of the COVID vaccine components, such as PEG, and then if you're acutely ill, we want you to wait until symptoms resolve, even if you have a COVID-19 infection. There's no known amount of time that if you have a current COVID-19 infection that we have to wait to give you your vaccine, but we do want to wait until those acute symptoms have resolved.

Even within the 90 day window of your own natural immunity, you can still get vaccinated, and I think it is a good idea to do so, because again, it will protect against some of those variants that we know are in our communities. Then lastly, if you were hospitalized with COVID-19 and received convalescent plasma, or monoclonal antibodies, we want you to wait at least 90 days. 

Then what about other vaccines?

We're still in flu season. So, your provider may be offering you the flu shot, or the Shingrix vaccine because you're over the age of 50, or maybe you're due for a tetanus vaccine. The CDC recommends waiting at least 14 days between the COVID vaccine and any other vaccination. 

These are some of the more common questions that we've been getting. What I'd like to do now is I'd like to pass this back to Jenn, and let her talk a little bit more about what your care center might be offering and how to get those resources. Thank you very much, and we'll be open to other specific questions and answers in just a moment.

Jenn Roberts:

Thank you, Dr. Heller. That was an excellent presentation. We do we have a lot of questions that have come in, and we should be able to get to all of them. I just wanted to remind everybody that all attendees will receive a link that's going to give them a copy of the PowerPoint, the recording, the link to our landing page on coronavirus advisory, and as always the contact information for your Vera care centers and prominent care centers and who you can call if you have questions about the vaccine.

I've got a bunch of questions for you, Dr. Heller, I hope that you are ready. 

Dr. Bruce Heller:

Okay, great. Thank you.

Jenn Roberts:

There's two different ways that you can send us questions, you can use the chat feature. If you look at the very bottom of your screen, there's a little square around it, chat, you can click that and type them to me, and you can also use the Q&A function and send that to me as well. Great, thank you. Okay. I've been trying to keep track of everything coming in, and one question that we got, which had a couple of different ways to say but was:

What is the major difference between Johnson and Johnson and Moderna and Pfizer? Specifically, why does it have a lower efficacy rate?

Dr. Bruce Heller:

Great question. In terms of efficacy, don't forget, these are all very, very highly efficacious. Remember, scientists were hoping to get between 50% and 70% efficacy. The difference between 85% and 94%, in terms of real world numbers, is not very much. I know people are concerned about what is the best vaccine? Really, the best vaccine is the one that you can get at the earliest opportunity.

The Johnson and Johnson vaccine as well as the AstraZeneca, or Oxford vaccine, which you may have heard about in the news recently, use a little bit of a different technology, they actually use a viral vector, and it's an adenovirus, which is another virus that causes the common cold. What the adenovirus does is it delivers a little piece of genetic material that again, codes for the spike protein, and then triggers an immune response. 

Now, the big difference with Johnson and Johnson is that it's a single dose. So, there's an advantage there. You can get fully vaccinated with one shot. Then the other thing that's a game changer in certain communities or worldwide, is that it doesn't need the deep freeze that the Moderna and Pfizer vaccines need. These can be stored and shipped at regular freezer and refrigerator temperatures. 

If you live in a rural area that doesn't have a big hospital system that has one of these very expensive deep freezers, you may be able to get the Johnson and Johnson vaccine much sooner than you could get either the Pfizer or Moderna vaccine. Those are the main differences. Remember, all of these vaccines are 100% effective at decreasing the chance of hospitalization or death from COVID-19. So, I would say, please get whatever vaccine is available to you as soon as possible.

Jenn Roberts:

Thank you, Dr. Heller, we definitely had a few questions on which one I should choose. I think, to underscore what you said, whichever one is available to you first.

Dr. Bruce Heller:

That's correct. Yep.

Jenn Roberts:

What if you have had COVID, how long do you need to wait before you get the vaccine? 

Dr. Bruce Heller:

Yeah, great question. Lots of people have had a COVID infection over this last year. We do know that natural immunity to another COVID infection lasts for at least 90 days, probably more, but we're not sure. We can say in confidence that you probably won't get another COVID infection within three months of the first infection.

There isn't really no recommended timeframe at this point after a COVID infection to get the vaccine, and I would say, again, piggybacking on our last comment is get the first vaccine that's available to you at the earliest opportunity, unless you're acutely ill. If you currently have acute symptoms of an infection of COVID-19, you have to wait until that is over.

Jenn Roberts:

We have a question about the window for your second dose. How many days after needing your second dose, let's say you missed it, could you still go and get your second dose?

Dr. Bruce Heller:

Great question. Some studies have been done that show that with Pfizer, they recommend a 21 day interval and with Moderna, a 28 day interval, but you can get it as early as four days sooner, and anytime afterward. We don't know the exact answer to this question yet. But we do know that it's not recommended to restart the series if you haven't gotten the second vaccine. 

This is going to become an issue if there are shortages. For instance, in a community that has say, 1,000 doses or something like that, and they give the first 1,000 doses to people, and then they get a second shipment of 1,000 doses. There might not be the doses that are available 28 days later, to get your second vaccine because they have already been given out to other people. We don't think that there's any change in your immunity if you get it one, two or three months afterwards. In fact, with some of these vaccines, for instance, the new vaccine that the WHO has just approved for emergency use authorization, which is the AstraZeneca vaccine, they're suggesting that a booster at 12 weeks is really the most effective. 

We don't know whether or not 21 or 28 days is the perfect time to get the vaccine. It could even be longer. But I would say, don't hesitate to get that first dose, and then anytime after the suggested interval, get that second dose and don't restart the series.

Jenn Roberts:

What if you've been fully vaccinated, is it okay for you to get together indoors with others who have also been fully vaccinated? Assuming this question is without social distancing?

Dr. Bruce Heller:

Yep. Such a great question, and the original studies for all these vaccines were done to see how much does it prevent serious disease. The studies are still being done to figure out whether or not the vaccines decrease transmission of the virus. What we do know is that the amount of virus in the people who have had vaccinated is much, much lower than those who might have an asymptomatic infection. 

It might not even be possible or it will be less likely to pass the virus on to others once you've been fully vaccinated. In fact, some new guidance has come out just this week from the CDC that says that if you've been fully vaccinated, and you're two weeks after your second dose, if you come into close contact with somebody who has COVID-19, you yourself do not have to quarantine, okay? The evidence is really showing us that it probably decreases transmission.

Now, in terms of getting together with other people, remember asymptomatic carriage is still possible. I would say that if you use the proper precautions and stay distant, you're probably okay. But I don't think that there's been any guidance that says, okay, guys, take off your mask and go have a party. Just use the typical precautions that we'd like you to do to decrease transmission of the virus.

Jenn Roberts:

Could you get your first dose as Moderna and second dose as Pfizer or vice versa, and as a follow up, would it be good to get a Pfizer or Moderna booster if you've gotten the single Johnson and Johnson?

Dr. Bruce Heller:

Great questions, really good questions. We think that because Pfizer and Moderna are both very, very similar mRNA vaccines, they're probably interchangeable. However, the recommendation right now is that if you got Moderna, you should get the booster with Moderna, and if you got Pfizer, you should stay with Pfizer. I think that we're going to know more in the future as to whether or not, not only if you had Johnson and Johnson, should you get one of the mRNA vaccines, but even the inverse, if you got one of the mRNA vaccines, should you get one of the other adenovirus vaccines?

That might be a way for us to get broader immunity and cover more of the potential mutations. But we just don't know that yet. I don't think that if you showed up at any vaccination center, that you would really be able to interchange the vaccinations, or to get a second vaccination with a different one. It's more of a theoretical question right now, but I think it's a good one, and it is being looked at.

Jenn Roberts:

We've gotten quite a few questions about specific health conditions precluding someone from getting the vaccination; severe cardiovascular disease or heart disease, severe allergies, allergies to egg. Are there any condition related or food related allergies that would make you not a candidate for the vaccine? If you can highlight that again.

Dr. Bruce Heller:

Sure. Great question. This comes up a lot. Just remember that this disease can be really deadly, and people who don't have maybe robust immunity or somehow or otherwise compromised with underlying conditions are at highest risk for complications and death from this disease. We've seen that over and over again, worldwide that older people and people with underlying conditions really suffer the most harm from this virus. 

If you have cardiovascular disease, if you've had heart attacks in the past, and if you have any underlying other major chronic conditions, you should definitely get this vaccine. In terms of serious allergies, if you've ever had an anaphylactic reaction, say to food or medication, for instance, penicillin, or a sulfur drug or something like that, or you've had hives, this is not a contraindication to getting the vaccine. Anywhere you go to get the vaccine is going to have emergency supplies on hand. These have not shown to be a major problem worldwide. 

For those who have a history of anaphylaxis, which is a severe reaction to something, you'll be observed for at least 30 minutes at your vaccination site. Most anaphylaxis reactions happen within the first, I would say zero to 10 or 15 minutes. So, 30 minutes is sufficient. Then you'll have your EpiPen and Benadryl at home if you need it over the next days. Was there another piece of that question, Jenn, that I might have missed? 

Oh, I wanted to mention eggs, thank you. There are no preservatives or eggs in either of these vaccines, and they were not produced using eggs like the annual flu shot is or certain varieties of that are. If you have an allergy to egg that is not a contraindication to getting the COVID vaccine.

Jenn Roberts:

You had a slide that you showed earlier and it was talking about the amount of people who could be vaccinated by mid-November with what we're expected by vaccines to be. Does that assume if 90% of people could be vaccinated by November 13th, is that the first shot or is that with the second shot? Then the follow up to that is what about people who are refusing to be vaccinated? Is that calculated in there?

Dr. Bruce Heller:

Right. Great question. First of all, just to talk a little bit about herd immunity, which is really going to be the threshold at which a community would not have epidemic proportions of A, an illness, even if it were to come into that community. Herd immunity proportions or thresholds really vary from illness to illness and vaccine to vaccine. We think, somewhere between 70% and 90%, is what's going to be needed for COVID-19. We really just don't know those numbers yet. But, it's a pretty high threshold.

The graph that was shown was only a single shot. Those are people who are at least partially vaccinated by those dates, okay? Again, if and when Johnson and Johnson comes on board, we could reach those numbers sooner, because remember, that's just a single vaccine. That doesn't take into account getting that second shot.

Now, in terms of those who don't want to get the vaccine, for whatever reason, those people obviously are going to be at higher risk, not only for getting COVID-19 themselves, but also potentially transmitting the vaccine to others. I don't have an easy answer for you, I think that there are going to be some legality and ethical concerns about this, particularly as we start to maybe vaccinate children either at the end of this year or next year. Just like with other vaccines, there are going to be state by state requirements. So, I think there's more to come on that.

Jenn Roberts:

I've got a question, actually, about the testing real quick. Which test gets you the results the soonest? Maybe a bit of background on which tests, and when? 

Dr. Bruce Heller:

Sure, good question. We, in our clinics have a rapid test, it is a PCR based test. So, it's highly accurate. But unfortunately, there are still quite a few false negatives for people who might be asymptomatic carriers. The rapid tests are really best when someone has symptoms, okay? If you are asymptomatic, you really should talk to your provider about which is the best test to get and when to get it. For instance, if you were just exposed, if you had close contact with somebody who was confirmed COVID-19 yesterday, and you don't have any symptoms, the guidance right now is to wait at least five days before getting tested yourself, because it takes that long for the virus to replicate enough to be detected in the test. 

If you get a test too early, you may have the virus, you may be a carrier of the virus, it's just not at a high enough level for us to detect, and you would get a false negative at that point. Timing is important. There are also rapid antigen tests that are being used, and these are being used in some work environments. Again, they do have a high false negative rate, but they can be used particularly with a strategy of repeat testing.

If you do a PCR test, which is the most accurate test, but might take a little bit longer to come back, even if you're asymptomatic, at the time of testing, if that's a negative test, we can confidently say you don't have the virus in your body. As opposed to some of these rapid tests, if it comes back negative today, we can't confidently say that you don't have the virus in your body. But if we test you every single day this week, or every other day this week, as the virus replicates in your body, we can find it just as it's becoming positive, and then we can ask you to stay home from work or school, or whatever it is.

I do know there are institutions that are using different strategies and different testing modalities to help contain this virus.

Jenn Roberts:

Gotcha. Just to summarize, this PCR test, which takes a little bit longer to get back is most likely to be able to see if you have COVID, no matter what stage it's in. The rapid test is most effective if you have active COVID symptoms right now, and the antibody test can be used as a strategy for daily or every other day basis to see if you're having a response. 

Dr. Bruce Heller:

Good synopsis except I hope I didn't misspeak and say antibody, I meant antigen, if I did misspeak. We don't use the antibody test at all in clinical practice.

Jenn Roberts:

Antigen, okay. We have a question about antibody infusion, that if you've had an antibody infusion, how long do you need to wait for the vaccine?

Dr. Bruce Heller:

Good question, Jenn. We do ask that you wait at least 90 days after getting convalescent plasma, which is really what the questioner is asking. This is one potential treatment strategy, which is that if we infuse antibodies from other people who have already had COVID-19, that it might help to act as a sponge and soak up the COVID virus that's in a sick person. If you've received antibodies like that, or monoclonal antibodies, which is the Remdesivir medicine that is made by Regeneron, that you may have heard of, those people need to wait 90 days before getting vaccinated.

Jenn Roberts:

We've got a question, a couple of questions about double masking. We've heard a lot about that in the news recently. What is all of that, Dr. Heller? 

Dr. Bruce Heller:

Yeah, great question. The double masking really came out of some of these new mutations or variants that we know are more infectious. What does infectious mean? That means that if you are in a room with 100 people, and one person sneezes, not all 100 people that are in that room are going to get sick with the same virus that, that person has. It really has to do with some viruses are more infectious than others. In this case, some of the variants of the SARS-CoV-2 can get you sicker at lower amounts, okay?

We're trying to look for strategies in the community that might, again, improve our resistance to transmission of the virus. What we do know is if you're wearing a single surgical mask, that there might be little air pockets, both at your cheeks and around your nose that allow not only respiratory droplets, or aerosols out, but also in. 

How can we make masks safer? One strategy is to wear a surgical mask against your face, and then to put a cloth mask over that. What that does is the cloth mask holds that surgical mask tighter against your face, and decreases those air pockets. There are also strategies that you can see on the CDC website that show you how to tie your straps of your mask to make it fit tighter against your face. These are not recommended, but if you want to wear a double mask, let's say you live in a community where you know there's high prevalence of maybe some of these variants, you might want to do that. Then this is really guidance as to how to do that in a proper fashion.

Jenn Roberts:

I think we have time for one more question. There's a few that have come in about this, but are younger people more likely to have some symptoms from taking the vaccine? It's a two-parter, how does that relate to the workforce? How long are people off of work? How will that impact the workforce from having symptoms or side effects after the vaccine?

Dr. Bruce Heller:

Yeah, good question. It does seem to be that people who are healthier and younger tend to have more of those side effects, particularly after the second vaccine. That's probably just because they're starting out from a place where their immune system is more robust, and then you give it a boost, and it really takes off. You can certainly take over the counter medication if you'd like if these symptoms are unpleasant enough. In terms of guidance for the workforce, not everybody has these symptoms and then the symptoms really range from mild to really shaking chills or sweats or malaise. 

I would say that, first of all, get your vaccines at the soonest opportunity possible, and then tell your supervisors or whoever is responsible that... For instance, in our clinic, we try to give all of our staff their vaccine on a Friday so that if they had unpleasant side effects that they would have the weekend to recover, and not have to miss work and be out of patient care. 

That's a strategy, you might want to plan to get your vaccine the day before you have the day off or a day you can work from home or something like that. But you really can't predict who's going to have the symptoms ahead of time. So, please just all get your vaccine, whichever one is available at the soonest opportunity possible.

Jenn Roberts:

I think that is a great note to end on. I wanted to thank everybody for participating today and awesome questions, everybody. I'm sure it's helping out a lot of people who were maybe shy to ask questions. I think we ran through all the different gamuts there on questions. 

Just a reminder that everyone who's attended today, and if you registered but couldn't attend, you will get a link that will give you access to the PowerPoint, the recording and our coronavirus landing page for more information. If you are currently a patient of Vera care centers or Prominent care centers, there's also information on how to get in touch with your provider so you can ask more detailed questions related to your specific situations and make appointments to get testing and vaccines as well. 

Thank you, everybody. Appreciate your participation, and good health, Vera. 

Dr. Bruce Heller:

Thank you everyone. Be safe.