I’ve been caring for COVID patients in New York for nearly a year now. Even with that experience, the incredible spike of cases in the late fall and early winter left me feeling helpless, like waiting for a hurricane.
Here’s what a typical day looked like: Wearing two masks (my N95 covered by a surgical mask), an impervious gown, and gloves, almost screaming at times so people could hear me through my masks, breaking the news to family members that a loved one is dying or dead.
All of that makes me grateful that I was able to receive both my vaccine doses early in the process. And I’m also grateful that we are rapidly increasing our vaccine distribution: Our average number of doses per day is nearing 2 million. Just this week, the FDA approved the single-dose Johnson & Johnson vaccine. Many more millions of Americans will have access to a vaccine in the next couple of months.
What should you know about the process and the vaccines themselves? For basic information like how to make an appointment or find out if you’re eligible, you should consult your state and local health departments. But there is plenty of important information that is less widely available. Here are some answers to some frequently asked questions.
What should I expect to happen when I show up at a vaccine site? What do I need to bring?
When I got my vaccine doses, I had to show my hospital ID to check against a list of eligible workers (eligibility at the time was limited to front-line workers seeing patients in the ER and ICU), and sign in on a registry.
Plan to bring documentation showing your eligibility within your state’s guidelines (a driver’s license or other official document that shows your age, and verification of your employment status.) Some sites limit eligibility to residents of a particular state or city to discourage “vaccine tourism” and therefore require proof of residency as well.
There’s one thing you don’t want to show up with: a recent vaccination for something else. It hasn’t been widely publicized, but getting any other vaccine within 14 days of your COVID vaccine is a contraindication. Plan your other immunizations accordingly.
My first dose came very early in the process. So after I checked in, I waited several minutes for a vial to be brought up from the hospital pharmacy. I made an appointment for my second dose while I waited. This is supposed to be the standard protocol for both the Pfizer and Moderna vaccines, that patients are given an appointment for the second dose before they leave.
After both doses, I went to a separate room to wait 15 minutes in case of a serious reaction. Even with that, the process took about an hour total for my first dose and about half that for my second dose.
What’s up with the side effects?
The most common side effects of both the Pfizer and Moderna vaccines are localized injection site reactions. With the first dose, I noticed a warm feeling in my vaccinated arm almost as soon as the pain of the needle itself wore off, and over the next two days my arm felt sore and heavy. I also felt slightly lightheaded and queasy the day I received the vaccine, but not enough to affect me at work.
Pfizer and Moderna report similar side effects. Besides injection site pain, patients can experience fatigue, headache, muscle pain and joint pain.
The second dose has been known to cause more serious effects. On January 7, the day of my second dose, I felt little soreness in my arm and I was otherwise symptom-free. The next day I started to feel lightheaded. And the day after that, Saturday, I started to feel some nausea, and I also felt tired and dizzy enough to want to lie down. Thankfully, I had that weekend off.
I felt well enough to return to work on Monday. However, I still felt tired, despite my weekend of rest, and felt enough nausea that I didn’t eat as much as usual. By Wednesday, six days after my second dose, my symptoms were gone.
An Atlantic writer recently described the effects of the second dose on her husband, a physician, this way: “tossing in bed, exhausted but unable to sleep, nursing chills, a fever, and an agonizingly sore left arm. His teeth chattered. His forehead was freckled with sweat. ”
If I do have side effects, what should I do? Is there a way to report them?
After I got the first dose of my vaccine, I signed up for the CDC’s Vsafe program. The program, available to anyone who gets one of the COVID-19 vaccines, sends text reminders every day for a week, then every week and asks you to check in.
The program started by asking if I had a fever. Then it asked me if I had any symptoms at the injection site: Pain, redness, swelling, itching, or “none.”
The next set of questions covered non-local symptoms, specifically, “Chills, headache, joint pains, muscle or body aches, fatigue or tiredness, nausea, vomiting, diarrhea, rash NOT around the injection site, none;” there was also a space to fill in “any other symptoms or health conditions you want to report.” Finally, the program asked if symptoms were “Mild: you notice symptoms, but they aren’t a problem;” “Moderate: symptoms that limit your normal daily activities’;” or “Severe: symptoms make normal daily activities difficult or impossible.”
There is another question that asks if symptoms made me “be unable to work, be unable to do your normal daily activities, get care from a doctor or other healthcare professional”, or “None of the above.”
The final message from the program was “Thanks for completing today’s check-in. Depending on your answers, someone from CDC may call to check on you.”
There is also a traditional reporting system, the VAERS (Vaccine Adverse Event Reporting Program), that has been in place for decades and mostly relies on health care providers to report vaccine adverse events. Patients (or caregivers in the case of minors) can also report reactions directly to VAERS through its website.
How long does it take for the vaccine to actually protect me from COVID?
This has been a pleasant surprise. Early reports on the Pfizer and Moderna vaccines seemed to indicate they were about 50 percent efficacious after the first dose.
However, more recent data shows a much more protective effect of the first dose. One study of vaccine recipients in Israel, showed the Pfizer vaccine actually is about 85 percent effective within two weeks after the first dose. Data from the U.K. shows an even higher efficacy of up to 90 percent three weeks after the first dose.
Also, according to a letter published in the New England Journal of Medicine by two Canadian physicians who analyzed available data from the FDA, the Pfizer vaccine could have as much as a 92.6 percent efficacy rate, and the Moderna vaccine a 92.3 percent rate, two weeks after the first dose.
What if I can’t get the second dose on time?
Ideally, you would be able to book your appointment for your second dose before you’ve left your first. Per the most recent CDC guidelines, although the recommended intervals between the two doses are three weeks for the Pfizer vaccine and four weeks for the Moderna vaccine, it is permissible to schedule the second dose as far as six weeks out. Health care providers are being advised, however, that even if patients show up for the second dose after six weeks, that “there is no need to restart the series.” Patients should receive the second dose and will be considered fully vaccinated.
Will the current vaccines protect me from the new mutant strains?
This depends on the specific vaccine, and the specific mutants.
A Pfizer/BioNtech press release from late January, as well as a “preprint” (non peer reviewed) version of the study results, indicated that the vaccine DID protect against strains of the virus with the N501Y mutation (found in both the “United Kingdom” and “South Africa” strains) that make the virus more contagious.
Unfortunately, similar tests against the South African strain specifically indicated a significant drop in overall efficacy, as much as two-thirds compared to other strains.
However, this was an in vitro (test tube) study testing to determine if neutralizing antibodies were present in the blood of patients who received the vaccine, which doesn’t always predict what will happen in vivo (that is, in “lab rats” or actual patients). Since there are many more components to the immune system, such as T cells, activated by the vaccine, the vaccine may still provide protection against severe cases of disease.
Moderna also has weighed in, with a statement that their vaccine offers the same level of protection against the U.K. variant, but possibly as much as a six-fold reduction in protection against the South African variant. To get around this, the company will be studying a possible third dose of a vaccine modified to be more effective against the African variant.
Pfizer is also considering a booster shot strategy to combat variants. Because both vaccines are mRNA-based, modifying the current versions to produce boosters effective against the new mutations could be accomplished in as little to six to eight weeks, something not practical for more traditional vaccines.
Once I am vaccinated, can I stop wearing masks and social distancing?
This actually may be the most controversial question out there! The ”official” answer for now, per the CDC and most public health experts, is unfortunately NO—due to the fact that the vaccines are not 100 percent effective in preventing disease in vaccinated individuals, and we don’t have enough data to determine how effective they are in keeping the vaccinated individuals from spreading the virus to others. It is theoretically possible for a vaccinated person to be protected from the disease, but still harbor—and shed—just enough virus to still be contagious.
However, the conventional wisdom has started to evolve, as more evidence has started to come in. A recent study from the UK found that two doses of the Pfizer vaccine cut the risk of transmission by 86 percent; another, from Israel, found an 89.4 percent reduction. While data for Moderna has yet to come in, the similar design likely indicates similar efficacy. Other studies designed to measure the effectiveness of vaccines in preventing transmission are ongoing.
CDC guidance regarding mitigation measures for the vaccinated has, so far, only extended as far as exempting the fully vaccinated from the usual 10-day quarantine requirement after a COVID-19 exposure, and only for 3 months after the last dose. The CDC was expected to issue new guidelines as early as this week, but stated Wednesday that the measures “had not been finalized.”
Outside the realm of official government public health agencies, many health care providers are already starting to advise loosening their restrictions, with some stating they would feel comfortable having their patients—or themselves—travel by plane after being fully vaccinated, albeit while continuing to practice other mitigating strategies.
Dr. Monica Gandhi of UC San Francisco has stated that vaccinated people can likely “mingle” and even go to a party together, but as the risk of transmission is likely not totally eliminated, they should “keep it safe and keep our masks on around the unvaccinated.”
Johnson & Johnson’s vaccine just got approved. Does it measure up?
The FDA approved the Johnson & Johnson single-dose vaccine last weekend, and it offers some practical advantages over the Pfizer and Moderna vaccines: A one-shot protocol is easier to adhere to, and the vaccine can be stored in a refrigerator for up to three months, as opposed to a freezer.
This is because, in contrast to the mRNA based Pfizer and Moderna vaccines, the vaccine uses different technology that is closer to a conventional whole-virus vaccine strategy. The vaccine contains an adenovirus, a common cold virus, that has been genetically modified to be harmless, and to contain DNA that codes for the SARS-COV2-spike protein. Once the virus enters cells, the cells will produce spike proteins and the body will mount an immune response.
However, the data showing better efficacy for the first dose of the Pfizer and Moderna vaccines than initially reported, reduces some of the advantages of the one dose protocol. The overall efficacy numbers of the Johnson & Johnson vaccine to prevent moderate to severe disease are rather low (at 66 percent) compared to the mRNA-based currently used vaccines, but it HAS been shown to be 85 percent protective against severe disease.
One encouraging piece of data is that the vaccine is 100 percent effective in preventing COVID-19–related hospitalization and death. The side effect profile of the vaccine is similar to the Pfizer and Moderna vaccines; nearly half of volunteers reported injection site pain, while about 30 percent to 40 percent reported headache, fatigue, muscle aches.
Per recently released documents, the J+J vaccine has been tested in South Africa, and while it has been only 58 percent effective overall there (compared to 72 percent in the US), it is still about 82 percent effective in preventing severe or critical disease.
It should also be mentioned that since the clinical trials for the J+J vaccine were held later in the pandemic than the Pfizer and Moderna vaccines, some of the overall decreased efficacy numbers could merely reflect the changes in the genetic profiles of the circulating viruses. If the Pfizer and Moderna vaccines had also been tested at the same time, their overall efficacy rates might have looked worse, as well.
The relative pros and cons of various vaccines will likely become more apparent as more data accumulates from their uses outside the tightly controlled clinical trials. As of now, however, the best vaccine is the vaccine that you can find!
Dr. Akino Yamashita is board certified in internal medicine. She is currently practicing in New York City.
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