Roy Exum: We Ramp Up

Monday, January 18, 2021 - by Roy Exum
Roy Exum
Roy Exum

As you know, federal and state employees will honor Dr. Martin Luther King’s birthday today (Monday) so it will be tomorrow (Tuesday) when the vaccination efforts to stop the spread of the COVID-19 virus in Hamilton County will really begin to ramp up. This week will also mark the start of “Round Two” for our First Responders, our medical providers, and others who were given their first doses of the vaccine three or four weeks ago.

Two types of vaccine are being given in Southeast Tennessee. The Pfizer vaccine was the first to arrive so those who received it were told to wait a prescribed 21 days before the second shot, or “the ‘other half’ of the vaccine,” could be given. Others have been given the Moderna vaccine, universally believed to be equally as effective as the Pfizer brand. Moderna asked for a 28-day window before its follow-up dose is recommended.

At the same time, the Hamilton County Health Department is focusing on giving the first shot to everyone in the 75-and-up age group and, through an appointment service now available on the health department website, anyone who is eligible can get an appointment. (Yes, caregivers are encouraged to help those over 75 make an appointment, but only those who are over 75 can actually be inoculated.)

VERY IMPORTANT! No one is required by law to receive the vaccine. While every health-field official in the nation begs each of us (18 years and over) to be vaccinated as quickly as possible, there is no law or rule that keeps anyone from making their own decision, this in the name of every citizen’s rights, including freedom. Certain companies are requiring employees to get the vaccine, but there are no state or federal laws that dictate it.

There are a number of 75+ seniors in Hamilton County who do not have Internet access. These people, or their representatives/caretakers, are asked to call the County’s Emergency Management team at …
423-209-5399 -- Hamilton County Emergency Management Hotline
… where they will be assisted with a time and date, as well as which location. A certain number of each day’s doses are being specifically set aside to accommodate those with no Internet access.
 
* * *
 
THE NEW ENGLAND JOURNAL OF MEDICINE’ ANSWERS OUR QUESTIONS
 
The New England Journal of Medicine is one of the respected resources for health professionals around the world. Trust me, there are many articles that will swamp a lay person in the first paragraph, but the NEJM has just included a “COVID 19 Vaccine Resource Center” that answers questions we might ask that is tremendous.
 
Paul Sax, M.D., a Professor of Medicine at Harvard Medical School and an infectious disease specialist, provides concise and engaging answers to clinicians’ questions about Covid-19 vaccination and to the questions and concerns patients will raise.”
 
For example:
 
How long will the vaccines work? Are booster doses required?
 
Since the vaccines have been tested only since the summer of 2020, we do not have information about the durability of protection. Data from the phase 1 trial of the Moderna vaccine suggested that neutralizing antibodies persisted for nearly 4 months, with titers declining slightly over time. Given the absence of information on how long the vaccines will be protective, there is currently no specific recommendation for booster doses.
 
Do the vaccines prevent transmission of the virus to others?
 
Many commentaries on the results of the vaccine clinical trials cite a lack of information on asymptomatic infection as a limitation in our knowledge about the vaccines’ effectiveness. Indeed, this is a theoretical concern, since up to 40% of people who get infected with SARS-CoV-2 have no symptoms but may still transmit the virus to others.
 
Nonetheless, there are several good reasons to be optimistic about the vaccines’ effect on disease transmission. First, in the Moderna trial, participants underwent nasopharyngeal swab PCR testing at baseline and testing at week 4, when they returned for their second dose. Among those who were negative at baseline and without symptoms, 39 (0.3%) in the placebo group and 15 (0.1%) in the mRNA-1273 group had nasopharyngeal swabs that were positive for SARS-CoV-2 by RT-PCR. These data suggest that even after one dose, the vaccine has a protective effect in preventing asymptomatic infection.
 
Second, findings from population-based studies now suggest that people without symptoms are less likely to transmit the virus to others. Third, it would be highly unlikely in biological terms for a vaccine to prevent disease and not also prevent infection. If there is an example of a vaccine in widespread clinical use that has this selective effect — prevents disease but not infection — I can’t think of one!
 
Can the second dose be given later than 21 or 28 days and still be effective?
 
The goal of the first vaccine is to “prime” the immune response; the second “boosts” it. Although most participants in the trials received their second dose on or close to the scheduled time, there is no biological reason why receiving the second dose late would diminish the effectiveness of the vaccine, provided it’s received before too long an interval. In practice, the second dose should be given as soon as possible after the missed scheduled dose.
 
Do the vaccines prevent transmission of the virus to others?
 
(Excerpt) -- Many commentaries on the results of the vaccine clinical trials cite a lack of information on asymptomatic infection as a limitation in our knowledge about the vaccines’ effectiveness. Indeed, this is a theoretical concern, since up to 40% of people who get infected with SARS-CoV-2 have no symptoms but may still transmit the virus to others.
 
Nonetheless, there are several good reasons to be optimistic about the vaccines’ effect on disease transmission. First, in the Moderna trial,. opens in new tab, participants underwent nasopharyngeal swab PCR testing at baseline and testing at week 4, when they returned for their second dose. Among those who were negative at baseline and without symptoms, 39 (0.3%) in the placebo group and 15 (0.1%) in the mRNA-1273 group had nasopharyngeal swabs that were positive for SARS-CoV-2 by RT-PCR. These data suggest that even after one dose, the vaccine has a protective effect in preventing asymptomatic infection.
 
Second, findings from population-based studies now suggest that people without symptoms are less likely to transmit the virus to others. Third, it would be highly unlikely in biological terms for a vaccine to prevent disease and not also prevent infection.
 
Until we know more, however, we should continue to emphasize to our patients that vaccination does not allow us to stop other important measures to prevent the spread of Covid-19. We need to continue social distancing, masking, avoiding crowded indoor settings, and regular hand washing.
 
Should acetaminophen (Tylenol) or nonsteroidal anti-inflammatory drugs (such as aspirin) be taken BEFORE the vaccination to prevent post-vaccination symptoms?
 
Although these drugs could decrease subjective side effects, theoretically they could also blunt immune response and make the vaccines less effective — hence they are not recommended before vaccination. They are useful, however, in diminishing side effects once they occur. Acetaminophen is preferred for pregnant women.
 
* * *
 
According to the State of Tennessee Department of Health on Sunday, there were 268 new cases reported statewide to give Tennessee 3,576 active cases.
 
Far better: according to the Johns Hopkins COVID 19 dashboard, it has now been 360 days since its debut and on Sunday the United States had 198,218 new cases over the past 24 hours and 3,286 deaths in the same time frame. Since the dashboard opened, less than a week this time a year ago, there have been 23,923,474 – yes, that’s millions – confirmed cases of the coronavirus and 397,494 Americans are dead since its arrival.
 
Globally … for keeps? 95,003,533 confirmed cases. 2,029,938 dead. Mind you: This in less than one year.
 

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