What to Do After You’re Vaccinated for COVID-19

I recently received my second of two COVID-19 vaccinations, which happened to be from Pfizer/BioNTech. Although it’s a big relief, and I’m much better protected now, it doesn’t mean it will change much that I do for a while. Let me explain why.

Vaccines don’t act right away. The way they work is to prepare your immune system to recognize something that is bad for you, so if it arrives your body is ready to attack it. But it takes time to do this. Imagine you’re running a race and someone is trying to chase you down before you can cross the finish line to safety. The faster they are, the more head start you need. What makes a bacteria or virus faster, besides the basic nature of it, is how much of a head start it has, which is basically how much of it you’re exposed to. It’s an over simplification, but supposed the virus doubles every 6 hours and you initially breath in 10,000 virus particles. After 5 days you’d have about 10 billion of them. After one more day you’d have close to 168 billion, a massive increase. So you have to have enough of a head start that the virus can’t grow to the point of overwhelming you. Every day after your initial vaccination is that much more of a head start.

Another way to look at it is to imagine you body is a village and a company of hostile enemy soldiers shows up. They would quickly overrun and capture the place. But suppose these soldiers were not not yet nearby but you knew they might attack. You’d have time to enlist people to provide more security, train them what the enemy looks like, and set up additional lines of defense. Then if they were to attack it’s likely you’d successfully fend off the attack, though you might be a little worse for wear as a result. But if they attacked with a larger force, such as a battalion, they could still overwhelm you.

So you can think of getting a vaccine as giving you a greater head start, or having more bodyguards. That should protect you from most situations, but you still wouldn’t want to run the risk of getting a massive exposure, or perhaps being someone who didn’t develop a good response to the vaccine. So wearing a mask, maintaining distance, etc. all minimize the risk. We don’t know yet how much exposure it would take to actually get someone sick if they have been vaccinated with sufficient time to be fully effective, so my concern now is just theoretical, but there are other reasons to remain cautious, particularly until the number of cases in one’s community falls significantly.

For one thing, the vaccine was 95% effective in the studies. That’s impressive, but it still means 1 out of 20 were infected sufficiently to have symptoms. For another, we don’t know if vaccinated people can subsequently get infected and not have symptoms, but be capable of spreading it to others. Finally, people who have not yet been vaccinated may feel anxious, or resentful, seeing people who are not wearing masks.

Some of my patients have told me they are concerned about the vaccine, and some of have even decided they just won’t get it. Let me address some of the concerns. One worry is the vaccine was rushed and they don’t know if they can trust it. Although it was rushed, it was mainly from everyone working longer hours than usual, companies prioritizing the research and production, and governments willing to promise to buy vaccine before before approved, with the risk that they could have spent billions on something that would never be used. The FDA did approve it before having longer term studies than usual, but given the risk of not being vaccinated, it was the right thing to do.

Although sore arms and flu like symptoms are relatively common, particularly after the second dose, serious reactions are very rare. You shouldn’t look at the risk without considering the context. Without a vaccine you have a high chance of getting infected. Those infected have a relatively high risk of serious complications, including death, particularly if older, or have various medical conditions. Those at the lowest risk of getting COVID-19 or getting significantly sick, will be the last to get it the vaccine, which means they will have the benefit of there being more experience with it. Even if you are not worried for your yourself, getting vaccinated is good for the community. We need to get a high proportion of the country vaccinated to reach herd immunity so the virus can no longer take off. Unfortunately there have been a lot of misinformation spread about the coronavirus pandemic, and politicization about it, but that doesn’t mean that these are not excellent vaccines.

I’ll have to see what happens, but between having been vaccinated, and the pandemic probably being much better controlled, I hope that I’ll finally be able to take a real vacation by this fall.

COVID-19 Vaccine – A Missed Opportunity

Under Operation Warp Speed, the government agreed to pay vaccine makers to produce vaccines ahead of approval to remove some of the financial risk, and get the vaccine produced as quickly as possible. It included a contract with Pfizer and its German partner, BioNTech, to produce 100 million doses of vaccine. Since each person requires two doses, that would be enough to vaccinate 50 million people.

As just reported by the New York Times, the Trump administration passed up the opportunity to buy additional doses late this summer, preferring to rely on other vaccines, having made 6 contracts to hedge their bet.

On 11/11/20 the European Union announced a deal to purchase 200 million doses from Pfizer/BioNTech, and the option to buy an additional 100 million doses. They said they may not be able to produce more for the United States until June as they now have other contracts. President Trump just issued an executive order prioritizing distribution to Americans, but I don’t think that is likely to have the force of law behind it.

Moderna has also applied for emergency approval of their vaccine. They said they expect to produce 85 to 100 million doses for the United States in the first quarter of next year. That would be enough for up to 50 million people.

So far that would get us enough to vaccinate up to 100 million people in this country by the end of March, assuming the companies are able to produce it at that rate. To put that in perspective, that’s only about 1/3 of the population. In addition, producing enough vaccine is only half the story. It then has to be distributed, and injected into people’s arms, which is a difficult challenge.

The Trump administration said that they turned down the option to purchase more vaccine because they are counting on other vaccines. Although they may come through, it seems like it was a big missed opportunity. The worse case scenario would have been we had more vaccine than we needed (well the worst would be that it turned out that the vaccine was either not effective or not safe). Think of the good will we could have earned by donating millions of doses, at a cost of only $39 to give two doses to each person. That’s a small price to pay to prevent a lot of illness, death, and damage to the economy.

The Coronavirus Pandemic Came and Atlas Shrugged

No, I’m not talking about Ayn Rand’s novel, though there are parallels.

The United States is now heading into its third wave of SARS-CoV-2 coronavirus cases, which is the cause of COVID-19. With over 8 million cases diagnosed, increasing by over 56,000 per day, and over 220,000 deaths, our top scientists are being silenced and bad mouthed by President Trump and his administration.

So whose advice is President Trump listening to? That would be Dr. Scott Atlas, who has said that masks don’t work, and that quickly spreading the disease to develop herd immunity would be a good thing, shrugging off the idea that herd immunity that did not come from a vaccine would come at the cost of potentially millions of deaths.

At a town hall Savanah Guthrie pointed out that Dr. Atlas is not an infectious disease expert (or an epidemiologist for that matter) but Trump said, “Look, he’s an expert. He’s one of the great experts of the world.” He’s a neuroradiologist, so I’ll grant him expertise in MRI images of the neck, but he should not be influencing how we deal with this pandemic. I wouldn’t want Dr. Fauci or Dr. Birx to be responsible to interpret an MRI, and we shouldn’t want Dr. Atlas affecting how we manage this pandemic.

Leaving Against Medical Advice

When a patient leaves the hospital against the recommendation of their doctor, whether it’s to return home, or to go out for a smoke, it’s called leaving against medical advice, or AMA.

Yesterday President Trump left the hospital briefly so he could see his supporters on the streets near Walter Reed Hospital, where he has been hospitalized for COVID-19. In my book, he left AMA.

Not only did he needlessly put at risk the Secret Service agents who drove him around, but he put his own health at risk. If he is sick enough to get put on remdesivir, which is only approved by the FDA for emergency use, an experimental antibody cocktail that has only been approved for experimental use and was authorized on a compassionate basis, and the steroid dexamethasone, which was only found to be beneficial in those requiring mechanical ventilation or oxygen, then he is sick enough to remain in the hospital until he is ready to leave.

I attended the Uniformed Services University of the Health Sciences (USUHS) medical school, where part of my training was at Walter Reed National Military Medical Center. One of the things taught us was that contrary to what you might expect, generals often get worse care. The example given was a doctor skipping the prostate exam he would otherwise do so as not to embarrass the colonel, potentially missing a prostate cancer. Although nowadays the value of a routine prostate check is debatable, the lesson was correct. It applies more so to this president, who may be at risk of being overly treated, and those around him not insisting strongly enough that he follow doctor’s orders.

Covid Calculations – It’s Tough

Given the COVID-19 pandemic it’s difficult to know what one should do about so many things, including what activities are safe, what precautions one should take to avoid getting infected, what to do with investments, and whether one should send their kids to school.

As a physician I often give advice to my patients regarding coronavirus. Unfortunately the current administration has politicized the coronavirus pandemic and provided inaccurate and inconsistent messages. They denied it was a problem for a long time, and even now discourage a large number of people from wearing masks.

Besides giving out false information from the very top, they’ve had a corrupting influence on our institutions that deal with this pandemic, affecting our ability to deal with it.

For example, with very short notice hospitals were directed to stop sending hospitalization information to the CDC, and instead send it to the Department of Health and Human Services, only to later reverse course because the data was not being processed correctly.

The Centers of Disease Control (CDC) is world renowned has has trained scientists around the world. They now have to run pandemic related news through the White House and have made many changes and removed documents off their web site due to political considerations. Recently they changed their recommendation to stop testing asymptomatic patents, prompting two scientists, one of which had won a Nobel Prize and was director of the National Institute of Health, to say that we should ignore that advice.

A week after President Trump publicly pressured the FDA to approve a vaccine, the head of the FDA said he might approve a vaccine, in certain circumstances, before Phase 3 research was done. These are the experiments that show that something is safe and effective. The name of the federal government’s program to develop a vaccine, Operation Warp Speed, and the frequent predictions by government officials that we would have a vaccine this year, suggests that they may be willing to cut corners. We should proceed as fast as possible, but it should be based on solid scientific principals and consensus. Even if the decision is made to give up some safety and assurance of a vaccine working because of concerns about the economy, it should be a conscious decision and not pretending the science is something it’s not. We already have a big problem with people distrusting vaccines in general. If an approved vaccine has unexpected problems, it could keep people getting many vaccines for a long time.

President Trump has touted other treatments, including hydroxychloroquine, bleach, and plasma. The FDA just approved emergency use of plasma, despite not having good evidence yet. That will make it harder to recruit patients into research studies, where they might get a placebo, making it all the harder to find out if it’s really effective. Although some of things might have merit, these are things that should be done based on science, and a leader with no medical or scientific background has no business touting unproven treatments.

Recently Dr. Scott Atlas has the ear of the president. He has questioned the use of masks and suggested we encourage infections to get herd immunity. We’re not even sure yet if being infected confers long term immunity, but even if it does, assuming it takes 65% of the population to become infected, and 1% of those infected dies, that means we’d have over 2 million deaths in this country. Dr. Atlas is not an infectious disease specialist or epidemiologist. He is a radiologist who specializes in MRIs. But his qualification, from the White House perspective, is that he has appeared on Fox News multiple times, and it resonates with what they want to hear.

My patients trust usually trust my advice, but if I have to question what the FDA, CDC, and other government bodies tell us, it’s harder for me to give good advice.

Health Injustice

In spite of the COVID-19 pandemic, we’re now seeing large protests daily across the United States, and indeed in many places across the world, sparked by the unfortunate death of George Floyd by policeman in Minneapolis. The Black Lives Matter movement tries to address how blacks are unfairly treated, particularly by police.

This is a complex issue that dates back to when slavery was legal in the United States. I’ll leave the political and legal issues to others to discuss and will focus on health issues.

In the US the life expectancy for blacks is roughly 3 1/2 years less than for non-Hispanic whites as of 2014 according to the CDC. Why is that? It’s largely because they have more chronic medical problems, such as hypertension, diabetes, asthma, emphysema, obesity, and kidney disease. Why is that? Mostly because on average they are poorer, which leads to a worse diet, housing, working conditions, and access to health care. Why are they poorer? In part from racial injustice.

Even when blacks have access to good health care, they may be less likely to take their medications due to social norms, including distrust of the health care system.

With COVID-19 we’ve seen that black and some other minorities are at higher risk of getting infected, and are at greater risk of dying. So while participating in Black Lives Matters protests, they may be statistically at a higher risk of dying than from being killed due to racial injustice. Of course protests often carry risk, and for some it may be worth dying for. But do consider the risk of spreading it to others who may not want to die over it, and take reasonable precautions, particularly wearing a face mask, frequent hand washing, and maintaining social distancing as much as possible.

At the End of the Rainbow – UV and COVID-19

Recently I purchased a box on Amazon made by 59S to sterilize things using ultraviolet (UV) light. With the COVID-19 pandemic I have to think about masks that need to be reused, and my cellphone, keys, wallet, etc for the times I venture out. Sure I can wipe them down with disinfectant wipes, but those are in short supply, and can’t be used on everything.

This box puts out UV light in the 260-280 nm wavelength using LED lights, 15.6 watts, with a cycle of 3 minutes. The light is rated at 10,000 hours. That would be 200,000 treatments, though I’m not sure the zipper would last that long.

Given the almost $200 price, I was not only concerned about the possibility of having been ripped off, but was even more concerned that it might not work as advertised, and that things I thought had been sterilized might not actually be safe. Just because ultraviolet light is proven to be effective does not guarantee than any particular device works as advertised.

So I decided to purchase some Columbia Blood Agar, 5 Percent Sheep Blood plates to do a scientific experiment to test it. I used a method similar to this video, though I used a sleeve to cover the front, back, and sides of half of the petri dishes. Rather than a pure source of E coli, I just dipped a cotton swab in different sources (toilet bowl, dog water bowl, mouth). After a couple of days it clearly showed that the UV light worked with the bacteria only growing on the half that was shielded from the light, as shown below.

This box has 12 LED lights on the top and 12 on the bottom. So I knew it worked when exposed from above. The petri dish sits on little wire stand so it’s much closer to the bottom, so I had no concerns about adequate light on the bottom side, but what about the front, back, or sides of an object that might not be directly exposed to the lights? So I repeated the experiment, but propped up one dish perpendicular to the bottom and facing the front, and another facing the side.

Thanks to the reflective surface inside the box, it still worked, but not quite as well. As shown below, on a dish facing the front, the clear portion does not extend to the top (The scattered colonies in the clear part were not visible earlier. I’m uncertain if it represents a low level that was not killed, or maybe new grown from contamination from the air while examining the plate. I didn’t start with a pure bacteria nor have the means to distinguish the bacteria.) I had similar results on the side, and repeating this portion of the experiment.

I think the problem is that some items may fall into a shadow where they don’t get direct UV exposure, and they either don’t get indirect exposure from reflection, or if they do, they don’t get enough. Although just running a repeat cycle may fix the problem, a better solution would be to move the item to change the surfaces exposed to the front and bottom, and then repeat the cycle.

In practice, even if not perfect, it certainly decreases the risk of getting infected from the surface of an item treated. Most of the time the infection doesn’t take hold unless the number of bacteria or viruses exceeds the ability of the body to fight it off. Being mindful of where the lights are and how you’re putting things in the box may help.

I recommend the manufactures add lights to the front, back, and sides and perhaps change to a cylinder like a hat box.

Most cases of COVID-19 are probably transmitted from person to person via droplets, rather than from surfaces, but for those who can afford it, this device may lessen the risk of contracting it, or other infections, and provide peace of mind.