Video and Transcript of Path Forward Ask Me Anything – Personal Health
Hi, there. Good afternoon. I'm Dr. Nahid Bhadelia. I'm an infectious diseases physician at Boston Medical Center and the medical director of the Special Pathogens Unit. I'm an associate professor at the Boston University School of Medicine. Over the last decade or so, my work has been working on providing care to patients with highly infectious, emerging infectious diseases.
I've been working on outbreaks and how we can avoid them, how we can respond to them, both here and abroad. I've been part of the Ebola response in West Africa, and in the last couple of Democratic Republic of the Congo Ebola virus disease outbreaks, have been part of the response on the Uganda side. During the COVID times, I have been working as a front-line physician, and I have been advising my hospital as well as all of you in terms of how do we survive this with our health and our sanity.
I welcome you to ask me anything about COVID, and with that, we'll jump right in and see what the first question is. Why don't we play the video, I think? Let's see what we've recorded, and then we'll go to the live questions.
Question: Hello. I'm Karen Tercek, president of the Willoughby Western Lake County Chamber of Commerce, tuning in from Willoughby, Ohio. My question for Dr. Bhadelia is, if you are fully vaccinated, can you be a carrier of the virus?
Karen, that's a great question, and the data on this has been really promising recently. What we know is that in the vaccine trials, such as Moderna, such as just as the workarounds from Novavax and Johnson & Johnson, we've seen that when patients ... and AstraZeneca, rather, I should say ... what we've seen is that patients who received their first dose, when they came back for their second dose, when they were tested, there was a two-thirds reduction of people who had any infection, even without symptoms, right? The concern is that you could get a vaccine, and maybe you don't get any symptoms but you could be a carrier, because enough of the virus replicates in your airway so that if you're around other people, you might be able to transmit it to them.
The most promising data is actually coming since the vaccines have been released, data from Israel, there was a study from Mayo Clinic, and then most recently the CDC released a study of front-line healthcare workers. In all of those cases, what we saw, the most recent study in CDC showed that there was almost an 80% decrease in all infections, any symptomatic infections or any infections where you may not be aware that you have the infection, so asymptomatic infections, an 80% decrease after first dose and 90% decrease after a second dose for the mRNA vaccines that are out there, which means that it's most likely that people who are vaccinated, their risk of transmitting the disease to others decreases drastically, and that's good news.
The only thing that we want to just be cautious about is that as new variants spread, we know that one of the things that they're doing is potentially decreasing the efficacy of the vaccines, particularly for symptomatic infections. They're protecting you against hospitalizations and deaths and severe disease, but it may be that, because of the new variants, there might be a little bit more room of you getting symptomatic infections or having potentially higher amounts of virus in your airway if you get infected after a vaccine. That's why we're all being extra careful currently in following the CDC guidance, and making sure that we're not gathering in large groups and all the other elements in terms of wearing a mask when we're around people who are not vaccinated.
Question: "What is the best COVID-19 vaccine to take, and how long do you think before the pandemic is over?" This is from Frederick at Georgia State University.
Frederick, I think I will echo what others have said, which is the best vaccine is the one that you can get today, for a couple of reasons.
One is, as I said, all the vaccines that are currently approved ... the Johnson & Johnson which is one dose, the Moderna and the Pfizer which are two doses ... all seem to reduce chances of severe disease, hospitalizations and deaths. People look at the numbers and trials and are stuck on the fact that there might be higher numbers in some of the vaccine trials for mRNA versus the Johnson & Johnson. The thing to consider is that you as an individual have a slightly different profile than everybody else. When you get a vaccine, the way the vaccine looks in you may look different.
From that perspective, the fact that all vaccines protect against severe disease and hospitalizations and deaths, and two, the fact that we know that variants, as I said, could affect vaccines' effectiveness and hence we will likely need boosters down the road for all of us, today's path to normalcy is as many people as possible getting vaccinated. By doing that, we protect ourselves. Because vaccines are reducing transmission, we keep the amount of virus in the community down, which means that any one of us individually are at less chance of coming across someone who has COVID-19, if that makes sense.
In terms of your question about the return to normalcy, I think it's going to be ... I think the director, Rochelle Walensky, has said this, and I think that this is probably the right way to think about it ... is that it's not going to be a flipped switch. It's going to be more of a dial as we return back to normal, and the first sign of normalcy that I hope to see is that as more of us get vaccinated, the cases start going down and hospitalizations and deaths continue to go down. If you remember, compared to where we were in November and December, and even the earlier surges, that is a sign of normalcy, when our health care systems can return to normal, and we're already potentially getting there as long as we can stay ahead of these spikes that we're seeing from B117 and some of the other highly transmissible variants.
The other signs of normalcy that we're seeing is the things that vaccinated people can do. We already know that we've seen guidance from CDC that people who are vaccinated can gather in small groups without masks on with other people who are vaccinated, or they can gather indoors with one other household where there are no members who are high risk, even if they have not been vaccinated. If you're a grandparent that's vaccinated, you can visit your nuclear family, your children's family, if none of those members are high risk and are not vaccinated. The guidance is still that if you're not in one of those groups, if you're potentially visiting somebody who's high risk, you continue to wear that mask.
The next steps I think you might see is that as cases keep going down ... and it's interesting, today Dr. Walensky brought up something that Dr. Fauci had discussed during the summer. What we want to see is the total amount of cases in the communities go down. Right now, we're at about 60,000 cases daily, and they talked about numbers such as even 5,000 or 10,000 cases daily.
When you get to that point, I think that it's likely the CDC and the U.S. government, the federal government, is going to feel a lot more comfortable passing guidelines that say you could now do bigger gatherings than where we were before, that you might be able to get back to some semblance of normalcy, such as gathering with your friends indoors for a dinner party, or what Dr. Jha has often mentioned, which is having small backyard barbecues with friends as well. Summer is going to see us do that. I think that you probably will see a greater number of people traveling, once more people have been vaccinated by summer, early fall.
I think the normalcy, the complete normalcy, the question is do we want to go back to complete normalcy, where people came in sick to work? I hope some things, lessons that we take from this pandemic, is how do we improve the lessons that we learned, like staying home when you're sick or wearing a mask if you go outside when you're sick and things along those lines. The normalcy for the rest of the world, unfortunately, is going to be much longer, because vaccinating the rest of the world may take years, and that might affect our ability to travel or interact or our ability to get back to normalcy, because we'll be worried that there might be transmission in other parts of the world. I hope that helps. What's the next question?
Question: "Will the COVID vaccine most likely be one that needs to be administered semiannually or annually, comparable to the flu shot?"
Tony, currently we know that there is a booster on the horizon, because we know that there are variants that decrease the efficacy of the current vaccines, and both Moderna, Pfizer and Johnson & Johnson, all three of them have started working on these potential boosters that address those particular variants.
Whether or not and how many years we need to have most likely annual ... or maybe even less than that ... vaccinations depend on how much continued transmission of the virus there is in the world, because the more this virus replicates, the more chances there are that it will mutate. The more it mutates, the more likely it is that it might find a variant that works for it as an evolutionary advantage, and hence, it is likely that then you might see variants pop up that are a threat and may reduce the efficacy of our vaccines. No fear, because we now have the technology and we've proven the safety of the technology, the vaccine technology. Even if that happens, we can quickly adapt our vaccines to address those variants.
It is unlikely, though. People have talked about whether you're going to be eradicating COVID-19 or not. It's probably unlikely that in the short term we're going to eradicate SARS-CoV-2, the virus that causes COVID-19, entirely from the face of the world, because there's just so much of that virus, but that's the hope. Maybe five, ten years down the road this thing becomes either completely manageable, or it becomes something that just disappears off the face of the earth. Right now, the goal is going to be to get it to a point where it's much less mortality, much fewer hospitalizations and people are healthy for the most part, except for some mild symptoms if they end up getting it. What's the next question?
Question: "Has there been any testing of new COVID vaccines for people who have autoimmune diseases?"
Beverly, the most common group that's been tested has been HIV. There've been other patients with autoimmune diseases, but not in large numbers in the vaccine trials. Currently, having an autoimmune disease is in fact not a contraindication. You should discuss it with your physician, whether or not you should be taking the vaccines, but prior history of autoimmune diseases or current autoimmune diseases actually puts you at potentially a greater risk of having a more severe COVID-19 course. That's why it is important for people to get vaccinated.
However, for particular incidents and particular conditions, I encourage you to talk to your physicians to see if you should be taking the COVID vaccine. I would highly encourage all my patients who are in that category to get it. The concern, though, is that even after the vaccine, you want to ensure that you are protecting yourself, particularly if your immune system is not as revved up as maybe other people's immune systems may be, because if you end up getting an infection, you would still be protected. It may be that you may be less protected than other people who do not have that condition. Next question?
Question: Good morning. My name is Peter Weber, of Winged Beaver Strategies in Washington, D.C. My question this morning is, if enough Americans don't get vaccinated, will the virus just continue to mutate and spread? What will happen?
Yeah, Peter, this keeps me awake as well. There's some good news on this front, which is that there's a Kaiser Family Foundation survey that says that the people who had said they wanted to wait and see whether they wanted to get vaccinated or not, that number is getting smaller. The people who are on the fence, the number of that seems to be going down, as we're getting more experience and millions of us are getting vaccinated with these safe vaccines.
I do hope that we end up reaching a point where there's not an issue, but vaccine hesitancy is a concern because that's going to delay for the reasons you talked about, because if there is a huge segment of our population where this virus continues to transmit, then you may end up seeing potential increased evolution. That's not just our population, but globally. If you keep seeing this virus transmit, the concern is that there aren't enough vaccinated people, that it will start to take a foothold and potentially develop new variants.
There is some concern here in the U.S. for me. The thought that I've had is that there might be communities and even states that do a very good job of achieving herd immunity, right? Large numbers of people accept it, particularly in some areas compared to others, and there might be other areas, geographical areas, with people who are hesitant, maybe in the same communities. You might see larger numbers of people not get vaccinated in those communities, and hence you might see outbreaks of COVID-19 in those communities where the vaccination rates are low, as we've seen with other diseases such as measles.
Before COVID-19, we were seeing outbreaks of measles, of vaccine-preventable disease, in Oregon and California and communities where there was a lot of sharing of potentially misinformation and disinformation about the measles vaccines. The rates were going down of vaccination, to a point where all of a sudden measles, which we thought we had controlled, was becoming a threat again.
That's the concern with COVID-19, is that all of a sudden you might get to a point in the United States where you may have communities that have achieved that, and then you might have herd immunity, and then you might have communities that might have lower rates of vaccination where we'll still see some of these infections end up in hospitalizations and deaths, and outbreaks happen and potentially the continued evolution of that virus, which might pose a threat for everybody else as well.
Question: "Does COVID-19 have any effect on the reproductive system?"
James, for pregnancy, for patients who are pregnant, what we know is that if you end up getting COVID-19 while you're pregnant, you're likely to have a more severe course of this disease compared to those who are not pregnant. That's why it's important. I think as the data is coming out in terms of safety of these vaccines in pregnant women, I think it's important to talk about why pregnant women should highly consider potentially having this vaccine after discussion with their OB-GYN.
The concerns that I have seen is not so much the COVID, but there's a lot of disinformation and misinformation about the COVID vaccine affecting fertility. There is no data that any of the COVID vaccines, or really even any of the other vaccines that are currently approved, have any impact on long-term fertility in males or females.
I think some of the reasons this confusion came out, I had a listener previously send me a note saying that one of the reasons that there was this confusion was that when we started talking about vaccines, scientists were talking about the concept of sterilizing immunity. Sterilizing immunity is a technical term which says if you get a vaccine, you are able to have enough immunity that you don't allow the virus to replicate in your airway. Basically, you've been able to sterilize your airway from that virus' ability to take hold.
When people heard sterilizing, I think there was a lot of confusion about, well, does that refer to how we generally use that term, which is the reproductive system. I want to take this time to again underscore, when people talk about sterilizing immunity, it's a technical term that they're using to define a type of immune response. It has nothing to do with the reproductive system or sterilization, and there's no evidence that COVID-19 vaccines affect fertility in males or females.
In general, in terms of COVID itself as a disease affecting male and female reproductive systems, we don't know yet. We do know that in pregnancy, it can cause a more severe course and potentially have some adverse effects for the baby as well, such as preterm labor. Next question?
Question: "What is your opinion on fully vaccinated people infecting non-vaccinated? How will science determine this?"
Kay, this is the question that we had started talking about at the very beginning that I am the most excited about, which is the evidence that we're now seeing, which is testing people who've been vaccinated to see. There are a couple of pieces of information that we have. I mentioned the CDC study that looked at front-line healthcare workers, that showed that people who are vaccinated have a reduction in all types of infection, which means that it's likely that if you don't get infected, you're not likely to transmit it. If the rates of your infections are low, it's likely the rates of transmission are low as well.
There's some other promising data as well. There's studies that have shown that people who are vaccinated, even if they get infected, the amount of virus in their airway tends to be much lower than people who are not vaccinated. There is good evidence on the fact that there is a reduction in transmission, but as I mentioned at the very beginning, the only reason we're being extra cautious right now is simply because there's a huge chunk of us that are still not vaccinated. There might be a concern that the variants, you may see potential for some of those rates of infections going up compared to with the wild-type virus.
Question: "Any updates on time for immunity following full vaccine?"
Dr. Fauci actually mentioned that today, and there's been some studies on this, Joseph, recently as well. What we know, I'll start first with natural immunity, like after infection. Not quite natural, because you don't actually want the disease, but immunity after natural infection. What we know is that there's antibodies that people have up to eight months or so, six months in patients who have had mild disease, but if you've been hospitalized, potentially higher. The trouble with natural immunity is that over time, your antibodies start going down.
Also, there is a concern that some of the variants that are out there, the B1351 or the variant that was initially discovered in Brazil, P.1, you're seeing potentially higher rates of reinfection with those variants in people who've had prior infection with the wild-type virus. It may be that, because the rates of antibodies that are created after natural immunity are lower than what you see after vaccines, that it's likely the vaccines are going to be a lot more protective. That's what we've seen in studies, is that vaccines tend to be a lot more protective against the new variants, compared to just having natural immunity.
From vaccines, the latest data is that there was a study that was put out from Pfizer that looked at, six months out, very strong antibody responses, but just bear in mind, it's not been that long since many of us have gotten the vaccine. It is likely, and general agreement is that if you get vaccinated, it is very likely, that that immunity lasts for a while.
It's hard to tell for how long, because it's not just the antibodies that decide the immunity. It's also your memory cells, T cells that decide it, and it is likely that the immunity from vaccination lasts even longer than what we see from immunity from natural infections. We just don't know. I'd hate to take a gander, but I wouldn't be surprised if there's some level of immunity even a year out, but we just don't know. That's just something that we have to take a look and document, I think, from studies.
Question: "I've been exposed to COVID-19," Diana says, "several times but have not contracted it. Is my body building immunities despite the fact that I've not been infected?"
Diana, great question. For you to build immunity, you would actually have to be infected.
It is possible that two things could have happened. You could have been exposed, but you may not actually ... you could have been around somebody who had COVID-19, but you've been lucky that potentially the virus didn't find you. Maybe the environment, you were outdoors, maybe you weren't in close enough contact so you weren't actually exposed, even though you were close enough to that person. Just by luck and chance, you were able to escape potentially being exposed to it.
The other option is you were exposed to it, but maybe the amount of virus was not enough for it to cause an infection in you. Particularly if you were wearing a mask, if the distance was long enough, it might be that you were exposed but the virus never took hold in your respiratory system. The third option is that you might've gotten it and had the infection, but you might've been asymptomatic and you may not have known.
To build immunity, you actually have to have had an exposure, and you might not have had any symptoms, but technically, medically, when we say you've had an infection, it basically means your immune system encountered it and it built a memory. That's what an infection is, even if you ended up developing those symptoms. For you to have developed immunity, you would have had to have had the infection, even if it's an infection without symptoms.
The best thing I would say is still get vaccinated and continue to wear those masks if you haven't had a chance to qualify yet for a vaccine. I would not assume that you are at this point immune, because there really aren't very many good tests on the market that can help tell you that you in fact have enough of an immunity to protect you next time you are exposed. I hope that's helpful.
Question: "How effective is the vaccine between doses? What happens if someone gets COVID in between doses? Should they still get their second dose?"
I'll start with the last question first. Currently the CDC guidance is that you should still get both of your doses, whether or not you've had prior infection, and that includes infection in between doses.
If you've gotten the vaccine, depending on the vaccine that you're looking for, you get partial immunity after that first dose. It really is that second dose in mRNA vaccines that really picks up your antibody response and is likely to guarantee that you'll have immunity for a longer period of time. In Johnson & Johnson, you get a big increase in your antibodies, and then over time that continues to increase at 45 days.
Can you get infected? You get partially protected, depending on what you're looking at. Right before you get the second dose, in some cases, like I said, there's about 80% protection in the mRNAs in the initial trials. It's not taking into account the variants.
What I would say is that there is still a chance. If your body didn't have enough time after your first dose to build that immunity, or you just happened to be unlucky and you got exposed to a lot of virus, you might still get sick after your first dose. It's just important to continue taking all the measures until you're completely vaccinated, which is two weeks after the mRNA vaccines and two weeks after the one dose of the Johnson & Johnson.
The interesting point that you bring up is that there is interesting evidence that shows that people who've had prior infection, now they have some amounts of antibodies in their body. If they get one dose, that they actually get a huge amount of immune response, and could that be enough. There haven't been trials done on this, and it's unlikely, Carly, from what we're hearing from FDA and the CDC, that there'll be a change in guidance.
There is some evidence that when you've had an infection before you get the vaccine, you become supercharged. You should still go out and get that vaccine if you've had the infection before, because it's just going to give you longer-term protection, like I said, and an increased amount of antibodies to protect you from the variants as well. What else do we have?
Question: "Can you get COVID-19 from the vaccine?"
Absolutely not. The virus that causes COVID-19 is SARS-CoV-2, and there is no SARS-CoV-2 virus in any of the vaccines. What the vaccines have is an instruction to build one part, one protein, the spike protein, that's part of the virus. That's what the virus uses to enter human cells.
Each of the different vaccines that are out there use different kinds of technology to deliver instructions to your cells to build that spike protein, which again, it's just one protein of many in that virus. There's no replication-competent virus. There's no virus, SARS-CoV-2, the virus, in those vaccines.
What you may be referring to is that when people get vaccines, part of the reason you're getting the vaccine is you're teaching your immune system to build a response. When you get a vaccine, you're likely to have those early symptoms such as pain at the site of injection, fevers, chills, body aches, muscle aches, and people may feel like they have a viral infection, but that's actually not a viral infection.
What that is is your immune system going through that battle testing and that training, so that next time you are exposed to the real virus, it recognizes that spike protein and is able to mount a strong response, enough so the virus cannot take a foothold, and even if it does, it cannot replicate enough to make you sick from the infection.
Question: "Is there any reason not to take Tylenol, acetaminophen, ibuprofen, etc., after vaccination to mitigate side effects?"
Theoretically, what the CDC suggests is that you don't take it before you get the vaccine, because you want to try to create an immune response. Some of these medications, the Tylenol, the ibuprofen, they tend to decrease inflammation, right? Part of that immune response is creating that inflammation so you get a memory. However, after you've gotten the vaccine, if you ended up developing adverse effects, the CDC guidance currently says you can go ahead and take those over-the-counter medications and then hydrate, so that your symptoms can be decreased.
Now, if you were to ask me, for no other reason except for there is a bit more anti-inflammatory component to ibuprofen compared to acetaminophen, I generally recommend that if you're going to take something on the day of, after you've gotten the vaccine and you've developed the symptoms in the vaccine, I lean towards Tylenol or acetaminophen over the ibuprofen, but probably it doesn't really matter. Just wait until after the vaccine, so that your body has that chance to build that inflammation and that immune response.
Question: "What are your tips for maintaining/increasing mental health as the pandemic continues?"
Yeah, this is incredibly important. I'm glad we're ending on this, because the rates of depression and anxiety have increased throughout this entire year. I've seen this not just through this pandemic, but part of my work during the West African Ebola virus disease epidemic as well as the outbreaks that I have been in in the past, when your entire normalcy changes, when you see how we live our lives change, your body will respond, right? Your mind and your body will respond together.
I think that we're going to need a lot more mental health resources. I hope that we see that investment from states. I hope we see that investment from hospitals in reaching out to their patients. If you are someone who's experiencing those symptoms, I highly recommend you take advantage of the resources that are available.
One thing that I do is still go out there, go outdoors, exercise. It is safer outdoors, to gather outdoors than it is indoors. I have been meeting colleagues, one or two friends. I would meet throughout this pandemic outdoors, at a social distance, for picnics. That's how I've kept my sanity and been able to get through this, is we wear masks, we keep physically distant and we do a picnic, and we take our masks off when we're farther apart and outdoors. That reduces the chance of transmission.
The other things that people I know have done is taken up hobbies and exercising, but truly I think that all of us are going to feel this, and it's okay to feel this, because we've all gone through a huge shock that has changed the shape of our world. We're almost there. Just hang in there a bit longer. We're almost on the other side of this.
Thank you for having me, and I'm happy to continue answering your questions on Twitter and thank you to the U.S. Chamber of Commerce Foundation for having me today. Thank you.