COVID-19 Update 12/2: All About Vaccines

Vaccines, vaccines, vaccines. As we get closer to an approved vaccine in the United States, we all have lots of questions. And on this week's update, Dr. Steven Bishop tries to answer as many of them as possible, from the reasoning behind multiple doses to how they work to what he's going to be looking for in the data. Watch the complete video below and read on for a transcript.

What is an emergency use authorization? 

And the first one we're going to talk about is "what is an emergency use authorization?" So a lot of you are seeing this term in the news media and other places and where the FDA is going to issue emergency use authorizations for the vaccines.

And what an emergency use authorization is, is an application that a company or manufacturer can put in for a medical device, a drug, a vaccine, whatever it might be, and says, "Okay, FDA, we have a new device, a new drug, a new vaccine for an illness for which there is no good known treatment or prevention. And we would like you to review the information we have on this in an expedited fashion, and go ahead and make a determination that we can market this. Okay. And sell it to the public."

And so that's what's happening with these EUAs — emergency use authorizations — both from Moderna, Pfizer and AstraZeneca. And it's actually the same with all the COVID tests. Many people may have forgotten about this, but all of the COVID tests, the PCR tests, the antigen tests, the antibody tests, these have all been approved under EUAs.

And again, that just means it's an expedited review process. The FDA still does a safety review. And there's a lot of onus put on the company, the manufacturer to say, "Hey, look, we really do believe these are safe products to use, and we've done our utmost to make sure they're safe and really do think that they work." And so the FDA expedites that process for them and issues an EUA.

So what does that mean? It means that again, they can go ahead and market the product, sell the product to the public. But there's still a lot of scrutiny that goes on in the EPA approval process and in the post-approval process. So the FDA for these vaccines in particular, they will be monitoring these vaccines very closely even after they are released and as they start to get delivered to people. EUAs are a shortened, expedited review process.

It doesn't mean that necessarily any corners were cut or anything nefarious was done. It just means that it didn't go through the normal, very lengthy FDA approval process that we typically would have for most drugs. And the reason that it's done is because there's an emergency. Okay. That's why it's called an emergency use authorization. There's an emergency. We have a pandemic. We have something going on. We cannot wait years and years for the FDA to complete its normal review process. We just can't wait that long. So we do have to expedite things some.

Are there some risks to that? Of course. Of course there are some risks to doing that. There's always things that come up with medications or anything else that we don't always know at first. And that's probably not going to be any different with the vaccines, but all things being equal, the FDA, the manufacturers, the scientific community says, "Hey, look. We realize this is faster than we normally would like to do it, but we've got a crisis on our hands and we really are going to have to move forward, because we do believe the preponderance of the evidence we have says that this product is safe."

What is an mRNA vaccine?

Next, we're going to talk about "What is an mRNA vaccine. So what exactly is an mRNA vaccine? I know we've talked a bit, you're seeing that in in the news, you're seeing that in other places. This term "mRNA vaccine." What exactly does that mean? What is an mRNA vaccine?

An mRNA vaccine stands for a messenger RNA-based vaccine. We have never before created a vaccine using an mRNA platform. Messenger RNA is a — think of it like a telegram — that a virus, or a human body uses these too in its own cells, it creates these little messenger RNAs from the DNA or the RNA in the case of the virus that then go to another part of the cell and tell it to construct a protein.

So think of it like a telegram. It's called a ribosome is the little protein manufacturing station. The messenger RNA goes from the virus or the nucleus of the cell to the ribosome and says, "create this protein for me." And then that little message gets turned into a protein.

The analogy kind of fits with the telegram, right? Because telegrams are turned from the Morse code into words. The messenger RNA is turned from the message into the actual protein. And then that protein is what then goes out into the cell and does its function for either human cell or for the virus. Out into the the viral package.

So what the mRNA vaccines do is they take advantage of this process and they, instead of trying to synthesize the protein or the full virus or change the virus in any way, they actually just takes a message to create a critical viral protein that the immune system is going to recognize and develop a response to.

Inject that message directly into the body. The human body then takes that messenger in, creates the protein, because again, it's like a telegram, the human ribosomes translate the message into a viral protein. And then when it comes out of the protein factory, the body says, "Hold on, this is not supposed to be here." And then creates an antibody and T-cell response to destroy it.

But then of course, that lasts. That immunity lasts, hopefully for a long time. And this is not that dissimilar from how all vaccines work, right? It's to trick the body into thinking it's infected with something, even though it's not actually infected, to create an immune response that then your body will remember the next time you're exposed to the virus. So that's what an mRNA vaccine is.

What's the difference between the Pfizer and the Moderna mRNA vaccines and the AstraZeneca vaccine and some of the others that are out there being evaluated?

Both Moderna and Pfizer are working on mRNA platforms. And that's what we just talked about. AstraZeneca is a little different. Theirs is an adenovirus platform. Adenovirus virus, many people may not have heard of this type of virus, but it's extremely common.

Adenovirus is another type of cold virus. It's in the same family as the rhinoviruses, the coronaviruses, it's all that kind of same family of upper respiratory infections. So what they've done is they've taken the adenovirus and they've put a gene in it that is from COVID-19. And it's a similar thing, right? Then they inject that into the the person and then the genes get encoded, the proteins get made, and then the body creates an immune response.

So it's just a little bit of a different approach. I don't think we have any other vaccines on the market right now that are adding a virus based. But we've used adenovirus technology for some time. It's a little bit older than the mRNA vaccine technology, but they are a little bit different. At the end of the day, it's a similar outcome which is to say it uses the genetic code of the COVID-19 virus in some way or form to create an immune response through vaccination.

Who will receive the COVID vaccine first?

That's a critical question. I know everyone is wondering about that. Who's going to receive the vaccine first? And when?

The vaccines I'm expecting based on what we've been seeing in the news, and it's probably not any different than what you're seeing in the news, is that the FDA should be reviewing the emergency use authorization applications from both Moderna and Pfizer within the next one or two weeks.

Once that happens, the companies say they can deliver the vaccine basically immediately, and they've already actually been stockpiling it. I saw a news report United actually Airlines has been flying the Pfizer vaccine to the U.S. to start stockpiling it. They will have it ready to ship as soon as it's approved. Each state, however, is going to get a certain allotment of the number of the vaccines, regardless of which company it is, based on their population size.

Here in Virginia, what we heard just recently was that Virginia is going to get about 70,000 doses in the, in the very first shipment. So not a lot because our population is much smaller than say in New York or California, right? So they'll get more doses than we will.

Virginia has said, and I think most states are following the same pathway, is that they're going to deliver the vaccines to two priority groups first. And that's going to be healthcare workers and people who are in long-term care, assisted living nursing homes. And those are the highest risk people.

That's who's going to get the vaccine first in the very first waves in those first kind of four to eight weeks. That's going to take up all the vaccine that's going to be available. That's who's going to get at first. My expectation then once those people have gotten the vaccination is that they will then allow it for the general population, probably say 65 and up, and then they'll work it down from there as they create more and more doses. But that will be who gets it first.

What are the side effects of the vaccine candidates going to be? Are they out of the ordinary?

This is, again, a really important question for a lot of folks, and I know many people are wondering about it. So I'm not going to sugar coat it. The side effects of the vaccine seem to be "noticeable," and I'm going to use that word because it came from a press briefing and "noticeable" in 10 to 15% of people.

Which means that about 10 to 15% of people are going to, they're going to feel a little crummy for a few days, especially after the second dose of the vaccine. So you're probably going to have a mild fever, again, 10 to 15% of people. So on the flip side, what that means is that 85% to 90% of people will have very minimal side effects, maybe a sore arm, maybe feeling a little fatigued, but that 10 to 15% of people, they're going to feel really fatigued.

They might have a fever. They might feel like they have lots of bodyaches. They might feel like they have a mild flu or even a mild COVID for a few days. So that probably is going to happen to 15% of people or so.

That being said, it's really not that far out of line with what happens with the Shingrix vaccine, the shingles vaccine. So about that number of people or more after the second dose of Shingrix actually get a lot of these same symptoms. They feel very tired. They feel crummy. They have bodyaches. They feel kind of yucky, even a low grade fever for a few days after the second dose of Shingrix.

So to me, I'm thinking of it kind of like Shingrix in that way. Time will tell of course. We'll see how it goes as people start to actually take the vaccine. But that's what I'm expecting. I'm expecting it to be somewhat similar to that. And a fair number of people will have some side effects, especially after the second dose.

The good news is that the side effects are not life threatening. And it does not represent an actual COVID infection, which is great, right? So even if you feel crummy for a few days, it's not going to be life-threatening. And it's certainly not going to develop into a COVID illness that's going to become very bad or life-threatening. So even if you do feel kind of crummy for some days after you take it, it's still safer than getting COVID for the vast majority of people.

Why do you likely need two doses?

Two doses is pretty common. Two or three doses. Regimens are pretty common in vaccines. The hepatitis vaccines are multiple doses. MMR, polio. The COVID vaccine is not going to be any different in that way. Shingrix that we just talked about, they are multi-dose vaccine regimens.

The reason for that is because the immune system often needs to be sort of primed. And that's a way to think about it...it's sort of a priming function because it's not an actual infection. The immune system doesn't always create long lasting immunity after just one exposure to a vaccine. It may be considered not enough of a threat to the body to create a long lasting immunity. So often we need to do multiple doses of a vaccine in order to get it to work.

This is very common in the vaccine world. It's not something that's out of the ordinary or unusual. Same thing, you know, you have to get multiple doses and boosters of other things. The same thing... The immunity can wane and sometimes the immune system has to be re-primed. And the initial vaccine of many things requires multiple doses. So to me, that's not very unusual and kind of expected.

What is the process for a doctor's office going to be to apply to receive vaccines?

Initially, the CDC put out some guidance and they were asking for a lot of information and kind of told us to get ready some applications. But then they've decided that they're going to let the local health departments decide about this.

What we've done, we've notified the health department locally here and in all of our areas where we have practices, and your doctor's office if you're not one of our patients will do the same, say the local health department. "Hey, we want to be a vaccination site."

And then they sort of put us on the list and then when the vaccines become available, they will let us know and deliver the vaccine to us. I know at one of our offices at least, in Northern Virginia, the health department has already reached out and asked how many healthcare workers we have working there, so they can start planning for distribution.

I think that that's probably what will happen. We'll get a call from the health department, and most doctor's offices are probably the same, saying, "Hey, how many people have working there? How many of them want the vaccine?" And they'll deliver them.

From there, I know that for the nursing homes, they're going to be using some of the national pharmacy chains to help distribute them to the nursing homes just to help make that simpler, like CVS, Walgreens, that sort of thing. So for the nursing homes and long-term care facilities, they will be working with some of the pharmacy chains for that, but for the doctor's offices and hospitals, it's probably going to be contact directly from the health department to get that those logistics worked out.

So what is the expected timeframe for everyone to get the vaccine?

It's a little hard to say. I think it's probably going to take six or eight months. That's my guess. And that's based on what some other people have said, too. Pfizer said they were going to have 60 million doses available within a couple of months. And that means that's only enough for 30 million people, which is 10% of our population. So I think it's going to take some months for them to be available.

Now, if Moderna is able to come in and Pfizer both get approved, then that will be faster, obviously. But I'm thinking that's probably going to be the summertime before it's widely for anybody who wants it. My guess is early spring for higher risk people, you know, sort of age 65 and up or people with health problems, I think it will be available to those people probably March, April. And then the younger, the healthier people who are lower risk probably in the summertime. That's my expectation for the timeframe.

How do I know which vaccine to get? Or will I even get a choice?

That's an interesting question. I think it's really going to depend on which of them get approved. So Moderna and Pfizer probably will get approved here shortly.

The AstraZeneca is going to lag a bit. They've had some issues where the trials got stopped for, for various issues. It doesn't seem that the problems were in the treatment group, but I think it is going to hold up the approval a bit.

So I think that Moderna and Pfizer are going to be the two that are available. AstraZeneca may come along a little bit later after the fact, but I think you probably, I mean, just to be totally frank, I think your choice is going to be whatever is available in your state and whatever is available at your doctor's office and your doctor's offices are probably not going to get a lot of choice in what they get.

It's probably they're going to take whatever they can receive from the health department and the CDC. I don't think there's going to be a lot of choice in the matter at at the practice level. I think the health department's going to call us and say, "Hey, we have X number of doses of the Pfizer vaccine? Do you want them? Yes or no?"

And that's going to be what it is. And so I don't think there's going to be a whole lot of choice in that. You can certainly wait until more vaccine is available or the other vaccine is available if you don't like the one that is available firsthand. I think that's totally fine. But I think the two vaccines are similar enough that, at least the first two, the Moderna and the Pfizer, that I wouldn't necessarily wait for one or the other. I would take whichever one comes to you first. I think that's fine.

Transparency of Vaccine Side Effects

Let's see, Ruth says, "I'd like to hear your comments about the transparency of the vaccine development testing side effects for the newly announced vaccines available that should be available soon."

Honestly, I think they've been about as transparent as they can be in order to keep the trials functional. Let me unpack that a little bit. Whenever you do a randomized control trial, you have two groups, right? You have the test group, and then you have the control group. Or the treatment group and the placebo group.

When you do a trial like that, you want as much as possible for it to be what's called a double blinded study. That means that neither the doctors who are giving the vaccine as part of the research group, nor the patients know what they're getting.

So if I'm a research doctor, I shouldn't know whether I'm giving this patient the treatment or the placebo and the patient shouldn't know, because we want to just see what happens without there being unnecessary bias introduced. There's some natural secrecy that's developed around controlled trials for that reason, because it keeps people's biases out of things.

I think that given the need for that, and the fact that that's so critical for a successful trial, I think that they've been as transparent as they can be with releasing preliminary results as they come and without divulging too much information about who's in what group until the full results of the trial are available.

What I'm hoping is going to happen over the next week or two is as FDA grants, I'm assuming , grants its approval for the vaccines, that Pfizer and Madrona both also publish all of their data for everyone to review. Because I think that's going to go a long way to helping people not be concerned and to helping answer questions that doctors and patients are going to have about side effects, about adverse events, and all those sorts of things.

I'm hoping that they will publish this information in tandem with the approval process so that people can feel more comfortable about what is going on there. I think to date they've been as transparent as they can be, but they are going to need to publish that data for us so that we can see what's going on sort of behind the scenes after the trials are completed.

CDC Changing Quarantine Recommendations

Kristin says, "I just got the alert that the CDC says you only have to quarantine for seven days, not 14, if you had direct exposure, but test negative. How long would you ideally wait to be tested, however, between exposure and testing?"

That's a great question. We tell people to wait about five days after exposure in order to be tested. '

And we just saw the news alerts and the updates on that quarantine timeframe change as well. I will be completely frank. The CDC has been a little wishy-washy on stuff and they change their minds a lot.

So my view is that I trust more of the Virginia Health Department quarantine guidelines. When they, if they change theirs, then I'll be more likely to change. But I'm not sure that that the given the problems with testing and the false negatives, I'm not sure it's a totally wise decision to cut the quarantine time in half.

Just because you've had a negative test, given that we know that the tests, if they're negative, they're not terribly accurate to be quite frank. So I'm not, especially when cases are rising, like they are now, I'm not sure that ideally, actually, this is a good idea, frankly.

Vaccines Approved for Certain Age Groups?

Carolyn says, "I heard something this morning on TV that when these drugs go for approval, they may not be approved without more testing for certain age groups. I think they're referring to possibly not having tested enough people in older age groups. This was kind of discouraging since age groups, really need this vaccine."

I haven't heard this thing specifically, but I know that the the major group, the three major companies have been trying to recruit more and more older patients into their trials. For this very reason, I don't think anyone under the age of 12 has had this vaccine tested on them yet.

They've started testing it on some people under 18, but not under 12 yet. But that was a, yes, a concern for the phase one and two. But I think in the phase three trials, they've tried to recruit more older people into the studies. But yeah, it is a concern. I think this is one of the reasons that we need to see all of the data published before we really start giving the vaccine to everybody. They need to publish that information so we can see exactly who it was given to, what age groups, what demographics, how it worked, what happened to them, are they doing okay? We need to see all of that when they approve the vaccines.

When does immunity start?

Kim says, "How long after getting the vaccine, can you expect to have immunity? I know with the flu shot, it can take a few weeks. How far apart will the second dose be given from the first?"

Yes, it's going to take about a month to get immunity. They're given about two weeks apart. So first dose you get on sort of day one. Day 14, you get the second dose and then two weeks after that the antibodies should be there. So it'll take about a month for the immunity to really kick in. So a little longer than the flu vaccine, but shorter than things like the Hepatitis A or B vaccines

Trial Participants Told If They Got the Vaccine? 

Delores says, "I had two friends that are in the Pfizer trials. Of course they have not been told if they got the vaccine,?"

Right. Yeah. They won't be told until the study is over or unless their doctor happens to check them for COVID antibodies.

We've had a few patients where that's happened. And we had found out what arm of the study they were in that way. Not advocating that necessarily, but that has happened for a few folks. And we have accidentally sort of "unblinded" them in figuring out what which arm of the study they were in.

If you could choose a vaccine, which would you choose? 

Kim says, if you could choose a vaccine — Pfizer versus Moderna— what would you you choose?

I'm not sure. Honestly, I'm not sure. I will probably take it. Again, I want to see the data published. I really do before I decide to take it. If I can see the data that will be much better. And I want to see that before I decide. That being said, depending on how long it takes, if the data is reasonable, I'll probably take whichever one is available first. I probably won't quibble too much about the Pfizer versus the Moderna myself.

Pharmacies or Doctor's Office First?

Theresa says, "Do you think the vaccine will be available at pharmacies or will it just be available in your doctor's office at first?"

I'm not sure. I'm not sure. It probably will be available at pharmacies and certain doctor's offices, probably larger doctor's offices and big hospital systems, but I honestly don't know because the the delivery logistics really haven't been that widely published.

I think it's probably going to be mostly available to specific doctor's offices that have said, "Hey, we want the vaccine." And then it's going to go to the big chains first for distribution to nursing homes.

And then once they have completed that mission, they probably will have a resupply for the general public. So I think they're probably going to be available in multiple places at different times, but probably it's probably going to be specific doctor's offices, first specific hospitals first, specific chains for giving to nursing homes.

And then I think you'll have a flood of supply by March, April that then there will be available kind of more widely for the people in the higher risk groups and sort of go from there.

Two doses of the same vaccine, correct? 

Debra says, "I assume the second dose should come from the company where we get the first dose, correct?"

Yes. Yes. You should get the two doses from the same vaccine. So if you start with Moderna, you stay with Moderna. Pfizer, stay with Pfizer. You get two of the same.

And what is probably going to happen, and this is what we do with Shingrix, when we get Shingrix in at least at our office, when we get doses in, we mark them for each person. So if I'm coming to get the Shingrix vaccine, I'm getting my vaccine today and then my second dose is set aside and marked for me when I come back in two months to get my second dose.

We'll probably follow the same process with these two. We'll make sure there's enough, two doses for a person before we start them down a path with either one.

Allergic to Meds — Should I Risk It?

Pat says, "I'm allergic to meds and I'm afraid to take the vaccine. Should I risk it?"

I don't know. And that is something that I think you and your doctor are probably going to need to have a good discussion about based on your risk for COVID, risk for having a bad outcome for COVID. And then again, I really want to see the adverse event and side effect profiles published so that we can really tell people what what's going on.

I think, in general, the vaccine is going to be fairly safe, but you're going to have that 10 to 15% of people that are going to feel really crummy. There will be some people who are frankly allergic to the vaccine, just like any medicine, antibiotic, whatever it is, who have an allergy response and that's going to happen to some people, it always does.

That's certainly a possibility, but I would talk to your doc about what your overall risk is for a bad COVID and then weigh that against against the vaccine.

I think for most people, especially if they're in that 60 and above group, I think that the risk of the vaccine is pretty low in comparison with getting COVID. For me, if I was aged 60 or above, I think it's really almost a no brainer. In general, go ahead and take it. The risks are pretty minimal, assuming, assuming, caveat, assuming, that the side effects are as presented or as advertised so far.

Length of Immunity?

Andy says, "Is there any new insight about the length of immunity and the need for re-vaccination? Science magazine published an article today discussing research suggesting that reinfection is more common than previously thought. If true, this seems like bad news."

Yeah. I think we just don't know. I think we just don't know. Dr. Fauci was addressing this the other day as well at one of his press conferences and he said, yeah, we just have no idea. And there's a lot of conflicting data that keeps coming out about this. We are seeing some people who are reinfected. The numbers are small, but it is happening.

And then by the same token, there are studies coming out showing that some people maintain an antibody response, and some people don't after a few months, and then also some people are maintaining a T-cell response for longer, for a number of months, too.

And so even if your antibodies go negative, you may still have a good T-cell response to the virus, which may be protective for the long-term. I'm just not sure how that's going to go at this point. I think we're just going to have to wait and see how long the immunity lasts. We're just going to have to wait.

Time will tell. I think my guess is it's probably going to be something we have to get a booster of. That's what my gut is telling me. Just because in general, humans don't always maintain strong immunities to coronaviruses for the long-term, because we get colds and things repeatedly, so I'm not sure that it's going to last for a lifetime.

I don't think this is going to be a one and done vaccine or two and done vaccine as it were. I think probably it will have to be repeated at some point. But that's my guess based on what I've seen so far.

Antibodies Disabling Key Immune System Proteins? 

Kim says "There was a recent article published that said people who have more serious reactions to COVID had antibodies that disabled key immune system proteins called interferons. It may be too early, but would this be something that we may want to test people for to determine if they're high risk and should be extra careful? Could having these antibodies impact the effectiveness of the vaccine?

I haven't seen the article. I'll have to read through it in more detail. But let me just read your question one more time. Antibodies that disabled key immune system proteins called interferons? That's really interesting. I haven't heard that. I'll have to look through that in more detail.

Now that that does bring up this idea of the cytokine storm again, which is really what is harming people when they get very, very sick. It's an out of control immune response. So in some ways the body creating things to tamp down the immune response may be helpful in certain people in certain situations. So I think there's a lot to unravel there with that particular question. I don't know. But that is definitely an interesting thing o think about.

Recommended Treatment Protocol? 

Kim, "Follow up question for both high risk and non-high risk people. What's the current recommended treatment protocol if you get COVID?"

Officially there isn't a recommendation for outpatients. We are telling people take Vitamin C, Vitamin D, and zinc because they're generally harmless supplements to take for most people. But other than that, we're not recommending anything. The FDA doesn't recommend anything.

If you are hospitalized or sick enough to be in the hospital, then there are treatment protocols with some of the drugs they have. Remdesivir and then dexamethazone, which is a steroid that is used pretty commonly, and antibodies, some of the antibody infusions as well, like Regeneron's antibody cocktail.

But those are being given to people who are very sick. For outpatient, there is no approved or recommended protocol at this point other than general good care, supportive care. And then, like I said, we're recommending that people take some multivitamins to help boost the immune system.

Back to In-Person School Anytime?

"Karen says, "I'm a teacher and I want to be back in school. I only had 10 in-person days with my students before the county switched back to all virtual until the end of January. What do you think the outlook is for being back to our hybrid model in February?"

Sounds like you were in Chesterfield, which is where I am, because my kids are back virtual until the end of January. I think it's going to depend on how quickly we can deliver these vaccines, honestly.

So a large, a big jump in cases lately has been driven by the cases in the nursing homes. I think that if we can blunt the cases in the nursing homes, then the metrics will improve overall, and people will feel better about getting back into the classroom.

But I think the next four to six weeks are really going to tell whether we're going to go back to even hybrid in February.

My gut says it's going to take a little longer but I'm not sure. I think it's going to depend on how quickly we can get the vaccine out and remember keeping in mind that once we get the vaccine delivered it and into someone, it takes a month for them to develop immunity.

There's going to be a 30, basically, a 30 day, well, a 28-day lag time between the first vaccine being given and the development of better immunity in the population. And again, remember Virginia for example, it was only going to get 70,000 doses in that very first shipment. So it's going to take a little time. It's going to take a little time, my guess is that we will not go back even to hybrid in February. That's what my guts telling me.

But again, unless both vaccines get approved and they're able to deliver a whole lot of doses really fast. I think it's going just take a little longer. Alright.

How Long to Isolate After Symptom Onset?

Amy says, "You mentioned updates to guidelines for quarantine. What about isolation guidance for people who test positive? I've heard the latest news says people are most infectious two days before and five days after onset. How long do you recommend people isolate after symptom onset?"

Yeah, so if you have a positive test, 10 days from your positive test date is how long you need to isolate yourself. So it's 10 days and feeling better. You have to have it resolved. Fever, cough is improving, all that stuff is going away or whatever it is your symptoms are have to be improving and 10 days after your positive test. So that's what VDH recommends. That's what a lot of the other health departments are using as well.

Should We Stay Home If We Can At This Point? 

Andy says, "Government leaders have been warning us that we haven't yet reached the peak of this horrible winter surge. Do you have a sense of how bad it may get with respect to hospital and hospital staff capacity and deaths? Should those of us who can do so remain at home to help reduce infection?"

Yeah, I think that the surge that we're seeing in a lot of places started even before Thanksgiving and probably will, hopefully not, but I think it will continue for a couple more weeks past Thanksgiving as well.

Our family, we made a decision, we're going to cut back on some things that we had started doing in the late summer and fall, going out to some restaurants that were being careful and things like that. But we are going to pull back from that and have pulled back from that over the last few weeks.

And I think most people should do that too. Especially because it's cold and we can't eat outdoors anymore in most places around the country. So I think that right now is a time to kind of just take a voluntary step back.

That way we don't find ourselves back in a bad situation like the spring, where people are talking about these draconian lockdowns and things like that. We would want businesses to stay open as much as possible.

It's critical for people's health and wellbeing that the economy continue to function. We can't have food without an economy. We can't have medicine without an economy. We can't have vaccine delivery without an economy. We need to keep the economy functioning.

In order to have that, we need people to take some voluntary steps back from certain things that they have been doing, especially if they're high risk people. But again, that's a decision that we made recently, too. We're going to take a step back from a few things that we've been doing to kind of reduce the risk of it there. Great question.

Healthy Before Getting the Vaccine? 

Debra says, "Do people have to be healthy before getting the vaccine?"

Generally it depends on what that means. If you're talking about like an acute illness, then yeah. If you already have a fever and you feel bad and something's wrong, you wouldn't want to get the vaccine while you're actively sick.

But if it's a chronic problem, diabetes, COPD, heart disease, something like that. Yeah, go ahead and take it. You wouldn't wait in that case, but if you're actively ill with something you wouldn't want to take it because it is probably going to make you feel worse.

Different Dosing Levels of the AstraZeneca Vaccine?

Amy says, "What's your take on the AstraZeneca vaccine and the different doses?"

Yeah, I'm not sure about that one yet. I feel a little less sure about the AstraZeneca vaccine than the other two, just because they haven't released as much data on it and they've had more issues with getting the trial going and keeping it going because they keep having these data safety halts.

I'm a little less I'm a little more leery, honestly, of the AstraZeneca vaccine at this point than the other two. I'm thinking that those two, the Pfizer and the Moderna, are going to get approved first. And then AstraZeneca will come along a few months later. And we may find that that's a better fit for some people than others and that that's fine. But I am a little more leery of that one. Right now.

Should I Avoid Contact? 

Ruth says, "My son is starting a new job in a clinical environment. No patient contact is expected. Should I avoid him?"

Probably not any more than you otherwise would. I think if you are self isolating in general, that I would continue to do that. I'm assuming maybe he lives with you or you see him frequently, if he's not going to have any patient contact, then I wouldn't treat him any differently than in his old job. Whatever you were doing before.

If You Already Had COVID, Should You Get the Vaccine? 

Linda says, "if you already had COVID, should you still get the vaccine?"

I was just talking with a friend about this last night, a friend of mine and his wife who are in their seventies recently had COVID and he was asking me the same question.

I said, honestly, I would get it, because again, we just don't know how long immunity will last and given, with this particular case, I said, given your age and your risk factors and everything else, I I wouldn't roll the dice twice with COVID. They did fine luckily. They had minor symptoms, did okay, and that's awesome, but I wouldn't roll the dice twice with it should they be re-exposed say in the spring or next summer and immunity has waned, so I would not roll the dice twice with this virus. So I would go ahead and get the vaccine.