COVID-19 Update 1/13: Vaccine Rollout, COVID Variants, and More

On this week's COVID-19 update, Dr. Steven Bishop discusses the messy status of vaccine rollouts, the three variants of COVID-19 that we now know about, what pregnant women should do about the vaccine, and more. Watch the video below or read on for a full recap. 

Dr. Bishop's Vaccine Experience: 1 Week After

Just an update. I'm a week out from my first dose of the Moderna vaccine right now, and Friday, I had a little fatigue and kind of feeling a little headachy about 48 hours after the first dose, but after that I felt fine and that's been most people's consistent experience with the first dose is fairly moderate to minimal side effects. I'll get my second dose next month. And we'll talk through that when the time comes.

Vaccine Rollout = Messy

So vaccines. Everybody is wondering about when can I get the vaccine? How can I get the vaccine? And a lot of our patients are wondering, a lot of my friends are wondering, and so we're going to talk about that for a few minutes.

The bottom line is that it is still very messy. The vaccine rollout right now is very messy. It's different everywhere. It's different depending on what county you live in, what health district you're in. Even in Virginia, from one county to the next, you may be in a different phase.

Essentially if you are a healthcare worker or someone who works in healthcare, and if you have not gotten the vaccine yet but you want to get the vaccine, the best thing you can do is go on to what's called the VAMS, the vaccine administration management system and register. Tell them you're a healthcare worker, tell them what you do et cetera. And you should be able to find a clinic near you where you can get a vaccine done. That's what I did. That's how I got my vaccine. If you're a healthcare worker, you should be able to do that.

Some counties in Virginia have moved on to Phase 1B of vaccine administration, not everywhere, but some places have. So Phase 1B, and again, this is basically health district by health district. So some counties are in Phase 1B and some are not.

Down where I live, they're not yet in 1B but some of the Northern Virginia counties, and over in Southwest Virginia, they have moved on to 1B at this point.

If you're in those counties and you are one of the frontline, you're an essential health care worker, you're 75 or older, or you might meet one of these other qualifications, a teacher for example, you might want to go over to VAMS, the website, and try to register and see if you can sign up for a vaccine at this point.

You may not be able to, you may be able to. It depends a little bit on whether your employer has put you in the system. Depends on what county you're in.

CDC Changes Recommendations for Vaccinations

Again, it's a bit messy. What has made this even messier is yesterday the CDC apparently changed their stance and they are now encouraging people to go ahead and vaccinate anyone 65 and up and anybody under 65 who has a chronic medical problem.

That's great. And I think that's good. The problem is that we don't necessarily have all the actual doses to do that. And even the doses that we do have are not being released in an efficient manner from the state government health departments, et cetera.

There's a lot of information flying around, but in terms of like vaccine on the ground, we don't have it. CDC changed their stance yesterday. That's good. The Virginia Health Department hasn't changed anything about what they're saying. I checked Maryland's as well. They haven't changed.

So I don't think anything has changed drastically in the last 24 hours, other than the CDC has said, "Hey, you need to start vaccinating more people." So we're basically waiting for the state governments to respond to that change in guidance, more or less, but you may try to go ahead and log into the VAMS system and register there and see if there's a vaccine available if you are, especially one of those 1A or 1B categories, you may be able to get a vaccine, again depending on your county and where you live, and if your employer has registered you there. Do check that out and and see if that might be an option for you. 

Will Virginia change recommendations? 

Brad says, "Is Virginia going to allow 65 and over to begin receiving it now as the federal government is now recommending?"

I hope so. I was just on the VDH website this morning. They had not changed any of their guidance. And they have not indicated that they have moved beyond Phase 1B, which is only 75 and up anywhere. They are saying no vaccine availability for 1C, which is people aged 65 and up. So essentially they have not responded to the CDC's change in guidance at this point. And I don't think most of the state governments have not changed their guidance yet, except for the ones that were already vaccinating people aged 65 and up.

Vaccine Availability

Carolyn says, "if you're over 75 years old in Chesterfield, my friend, his parents say their medical office doesn't know when they were have the vaccine."

Yeah, I'm in Chesterfield County. I actually went on through VAMS and they have an eligibility tool that you can use when you go to or excuse me, the Virginia Department of Health. If you go to that link, there is a tool to find out when you'll be eligible. And if you go through and put all your information and you choose Chesterfield County, and I chose that county because that's where I live, because I wanted to see what it would do.

And I choose, you know, said if I was a person who is 75 and up, it just asks you to put in your information so that you can be notified when that county's in Phase 1B. So they're not in 1B yet in Chesterfield County and apparently not planning to be today.

Again, you can try to register in VAMS so that they'll contact you perhaps, but they're not currently giving it or letting you go all the way through and schedule an appointment just yet with that. So not yet is the short answer and, and your friend's parent's office, yeah, we're in the same boat. We're still waiting to hear from the health departments.

Appointment for Second Dose?

Since you got your first vaccine, do you already have an appointment set up for your second one?

Yes, I do. I do have an appointment. It's at a different location than before, but I do have an appointment for my second vaccine. And that's part of the guidance that changed. The CDC is also saying, "Hey, don't hold that back just in the interest of making sure everybody gets a second dose, go ahead and vaccinate as many people as possible, and we're going to work with the manufacturers and try to make sure that they just keep producing enough doses so that there's plenty to go around for second doses, but don't hold them back."

So that's part of the guidance that changed also, but again the state governments don't seem to have responded to that change in guidance as of yet. I suspect we'll hear something different in the next couple of days from the state health departments.

Waiting for Vaccine Through VA? 

"My in-laws are over 75. They live in Richmond and have access to healthcare through the veteran healthcare system. Should they wait for the VA hospital to call as I've been told for weeks or go through the VAMS website?"

Now I would try to go through VAMS and see if that would work for them because it may be faster than waiting for the VA. I don't know if that's going to work out faster for them or not, but they may be able to get faster through that. And I know Richmond did announce today that they're going to move into Phase 1B, so it may be that they're able to get a vaccine faster that way doing, doing it through BAMS.

Mutant Virus Strains

I'm going to talk just for a minute about the the mutant strains of the virus. This has been a concern since the beginning of the outbreak that there were new viral strains coming out and worried about how that was going to impact people. And now there are concerns about how that may impact the effectiveness of the vaccines and some other things. So let's talk just for a minute about viruses and how they work and that sort of thing. And then we'll kind of break it down from there.

This particular virus is made up of RNA primarily. Any virus, just like a human cell, its objective is to replicate.

Viruses replicate a lot faster and a lot more frequently than human cells do, but whenever that's done, when the virus particle replicates itself using our cell's machinery, there are enzymes that replicate, the genetic material of the virus, in this case the RNA. And it makes just millions and millions of copies of the viral genetic code.

And that process is prone to error at a certain rate. It's a small rate, but the process is prone to error. There are tiny mutations of viral DNA all the time. They happen constantly. Most of the mutations fall into one of generally three categories. Either they have no effect on the virus at all. They make the virus worse in some way, or they make the virus less concerning in some way. So either no effect, more virulent, less virulent.

Those are some broad generalizations and a little over simplification there, but you can think of it kind of that way. So what is going to happen and what we're seeing is, in these new sort of strains of the virus, they pop up because that RNA copying process is prone to errors.

Every once in a while, you're going to get a new version of the virus that is going to be different than one of the other ones. And it may have some characteristic that makes it easier to spread, for example. And that's what we're mostly seeing. And we saw an Ohio strain, the Columbus strain they're calling it, that popped up in the last couple of days. And we've talked about the UK strain and the South African strain.

And most of that, what they have shown is that it's a minor genetic mutation in the way that the virus transmits itself. Whatever the gene that's encoded, this change makes it simple for the virus to travel from person to person and set up an infection. It doesn't mean that the virus is worse per se, in terms of it's not making people sicker. It just spreads faster based on this mutation.

And whenever that happens, and you've got a strain that pops up that can spread more easily, it's one of the laws of natural selection. If you think back to evolutionary biology and just simple math, if something can spread faster than another version of something, it's going to become the more dominant strain, because it spreads faster and then eventually it crowds out the other strains and out competes it for hosts, more or less, for lack of a better term as that's what we are to the virus, a host. So it's going to out-compete the other hosts because the other versions of it because it spreads faster. And so it becomes the dominant strain in an area, and then it spreads from there.

And that's what you're seeing with the UK stream, with the South African strain, and now this Columbus strain is actually very similar to some of the other strains that have popped up as well. So it appears that there are particular DNA copying or RNA copying errors that are popping up more frequently than others.

We see them because they confer what's called a selective advantage on that version of the virus, and then they stick around. So that's why we're seeing it more frequently. So it's easier to transmit. Doesn't make you any sicker.

Implications of Variants

Now, there are a couple of implications that seem to be going on here. There's three major issues or questions.

1. One, do these modifications affect the way that the medications we developed for the virus work? So the antibody cocktails with Regeneron, some of these other medicines, does it affect those things?
2. The second thing is, does it affect the the vaccine?
3. And then the third thing is does it affect the morbidity, mortality or the outcomes of the infections per se? 

It seems that it's not affecting the outcomes too much, except that it's increasing the number of people who have the illness. Now, there is concern that the antibody cocktails and other things, which were created very specifically for the main strain of the virus that was out and about a few months ago may not work as well with the new variants. So that is a concern that's being evaluated.

There is also a concern, and there was an FDA alert issued on 8th of January, that some of the variants may not be detected as easily with the PCR, the molecular tests that we have. In other words, it can create false negatives and we've had problems with false negatives on the tests from day one, but what may be happening is that because the gene, again, the genetic code, the virus variants are a little different, the tests are not detecting them as accurately as before.

So that's being evaluated. It seems to be a problem with certain types of tests and certain tests brands. We are in communication with our testing companies. I don't think it's an issue for the ones that we're using here at PartnerMD, but there are a number of tests out there that may be affected by that. Again, what that means is you might have one of these variant strains and you take a COVID test and it's negative, even though you really do have it. So that's a problem. 

Why Variants *Probably* Won't Affect Vaccine Efficacy

Now, the vaccine effectiveness, the thing with the vaccine effectiveness is that it, we don't think that it's going to be a problem.

And at least not in the short term. And this is a little bit different based on the...so think about the antibody cocktails that we made, right? So the Regeneron. That's a very specific set of highly specific antibodies that were created for one particular variant of the virus.

It's two or three different antibodies that were created. So even a minor mutation can make those antibodies no longer bind to the virus.

When you have a vaccine or natural infection from a virus, your body doesn't just make a couple of different antibody types.

Your body makes a whole portfolio of antibodies against the virus, a number of different configurations, a number of different types. And then you've got the B cell, or excuse me, the T-cell immunity on top of that. Again, there's a whole portfolio of those. So it's not just one thing or two things. It's probably thousands of different ones.

So even if there's relatively minor mutations in the virus, the antibody and the T=-cell portfolio that your body creates will still work as long as there are not massive wholesale mutations to the virus, which of course can happen over time. But for now, not suspecting that there's going to be a problem with the vaccine effectiveness based on the mutations that we're seeing so far.

Now, again, that may change over time. Again, flu shots don't last forever. You have to get them every year because the flu virus DNA does change quite a bit from year to year. And we may find that with COVID too. But so far doesn't seem to be the case. Hopefully that won't come to pass. But that's a little bit of what's going on with the strains and the variants and how that's going to impact testing and treatment and vaccines. More to be seen on that, but that's kind of a good a good overview of things to date.

How Long Do Antibodies Stick Around? 

"Is there any evidence in how long the antibodies stay in the body? Is it safe to be around someone who had the virus within the past month if they aren't coughing or running a temperature?"

Yeah. It's one of those questions we just don't know. We don't know how long the antibodies are going to be effective or stay in circulation. We're not going to probably know that for a year or more as follow-up testing is done.

And for, "is it safe to be around someone who had the virus within the past month?" Yeah. As long as they're out of their quarantine period you should be fine. After the 10 to 14 days, as long as they're feeling better, you should be fine to be around them. They're not infectious anymore.

And that's true even if their tests COVID test remains positive. It can remain positive up to six weeks in some people. So that's why for the most part, we encourage people not to get retested, because the tests are probably just detecting dead virus at that point that does not have the ability to infect people.

If somebody is out of their quarantine period, they don't need to retest. And you don't need to be concerned about being around them.

Which Vaccine Has Fewest Side Effects?

"Which of the approved vaccines has the fewest side effects? Also, when is the Oxford vaccine likely to be approved?"

Good question. So both Pfizer and Moderna's seem to have pretty similar side effects for the most part. I don't think that one is necessarily better than the other. I'm waiting to see some follow-up data on this. I suspect after a couple of months of giving the vaccine, we'll have some more information.

My anecdotal experience talking to people is that it seems that the Moderna one has a little bit fewer side effects than the Pfizer, but again, you can't really make a statement based on that because, we have to have data from tens of thousands of people to really kind of tease that out.

So the answer is I think they're probably pretty similar in terms of the side effect profile, but time will tell.

And I don't know when the Oxford vaccine is going to get approved. I haven't seen any announcements in terms of when they are going to submit their data to the FDA. Hopefully soon. Hopefully they'll do that soon. And then we'll be able to see that. But I think I did hear that they might submit it sometime this month, but haven't seen it yet.

Registering for Vaccine as a Teacher? 

"As a CCPS teacher, should I register on the VDH website or wait for CCPS to give me the vaccine?"

I wouldn't wait. I would try to register on VAMS and see if you can get a vaccine based on being in the 1B category, because I don't know when CCPS will actually get around to vaccinating people. It may take them some time.

It may end up being faster, but I would pursue both routes if you want to get the vaccine as soon as possible. I would pursue both of those routes. Pursue VAMS registration while you wait for CCPS to kind of figure out what they're going to do on that issue.

How Long for Antibodies to Work?

"How long does it typically take the body to deploy antibodies against a virus? Is it instantaneous when it first recognizes the first viral particle? Or does it take a few hours or days before it realizes it's time to go to work?"

Yeah, so there's, there's a couple things going on there. So there's two main branches of the immune system. There's the innate immune system and then there's the acquired immune system.

What's called the innate immune system is a sort of general threat monitoring response system. So it's something called natural killer cells and generic antibodies and something called toll-like receptors and other things that detect the presence of viruses, bacteria, fungus, and other things. And then they mount a general inflammatory response.

So that when you get it, when you get a vaccine, for example, and a few hours later, your arm is hurting and a little swollen and all that, that's the innate immune system reacting to something that's inflammatory in it. It's a very quick response within minutes to hours, that innate immune system is doing something to try to start combating the virus or the bacteria or whatever it is.

And what the innate immune system does is it then recruits the what's called the acquired immune system. And so that's sort of the, think of it like the special forces. They are very highly trained. They're very highly specific for a particular virus or particular bacteria or whatever it is.

And the acquired immune system does take some days to ramp up. So there's some time. There's some training times and development time. So it takes about 10 to 14 days before the acquired immune system has developed and deployed antibodies and T-cells and things of that nature that are specific for that particular virus or a vaccine, that sort of thing. So generally if you get a vaccine... About two weeks, 10 to 14 days before the protection is sufficient to be detectable and to be doing much of anything.

Vaccine for Pregnant Women

"Would you recommend the vaccine to a pregnant woman?"

That is a hard question to answer. I don't think there's a clear cut answer there. I think it depends a little bit on how high risk the person is otherwise. What other medical problems they have. And it depends on what they do.

You know, if it's a pregnant ER nurse who also has diabetes and three other medical problems, I think they should get the vaccine, because I think the risk in the vaccine is very minimal compared to the risk of getting COVID based on their job and their other medical problems.

Suffice to say, I think that's an extremely individualized case specific situation that probably each woman needs to talk to their OBGYN about, if they're either pregnant or planning to become pregnant.

It's just too specific for each person for me to give kind of a blanket recommendation. So my blanket recommendation in that case is talk with your OB and ask their opinion, based on your medical history and your risk factors. That's what I would say with that. Highly, highly individualized.