COVID Update 2/17: Vaccines, ITP, CDC Guidance After Vaccination, and More

On this week's COVID-19 update, Dr. Steven Bishop discussed the latest vaccine news, including a slight increase in supply and updates on the AstraZeneca and Novavax vaccines; recommendations for individuals with ITP; the CDC's guidance on transmissibility and quarantining after vaccination; and more. Watch the video below and read on for a full transcript. 

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Vaccine Supply Increasing Slowly

A couple of pieces of good news. One thing that I saw in the news today and yesterday is that the supply of vaccines from the federal stockpile is going up, which is good. Hopefully they are thinking they're going to be able to release about 20% more vaccines going out to the states each week, which will bring us to about 13 million doses per week to all the states, which is good. That's good that that's going up now.

I'm not sure if that is from manufacturing increasing, or if it's from them making a decision to release more from the stockpile. I think it's from manufacturing increase just based on kind of reading between the lines, but that is a good news. So more vaccine coming down the pipe and that'll be helpful for a lot of states and a lot of places who are still struggling with supply like we are here in Virginia, where we are quite limited still.

Novavax and AstraZeneca Update

Another good piece of information is Novavax, which is another vaccine. We've got a number of candidates sort of actively going now. We've got Moderna, which has got an emergency authorization. Pfizer has an emergency authorization. And then we're expecting Johnson & Johnson to get authorized at some point for their vaccine. So Pfizer and Moderna are both mRNA vaccines.

I think everyone's fairly well aware of what that is at this point. The Novavax one is a little bit different. It's a protein sub unit vaccine. And that is actually really similar to the hepatitis B vaccine, which is good. I suspect it will be very safe. It seems to be effective based on the data that's coming out of the trials from the United Kingdom.

And what's good, too, about the Novavax, is it seems to work well against both the UK variant and the South African variant, which is really good news, because it seems that the the Pfizer and Moderna ones may not work as well for the South African variants.

The AstraZeneca one, which is the other main one that we're still waiting on approval in the US, for is the adenovirus based vaccine. Starting to have trouble keeping them all straight because we've had so many out there, so that's good news.

Hopefully Novavax will get approved at some point. I know they are still working on their trial, and the AstraZeneca trial is actually not yet completed either in the US and I was just looking at... It looks like that one's going to be completed February, let's see, estimated primary completion date, March 23rd of 2021. So I don't think we will see data or any movement on approval on the AstraZeneca vaccine here in the U.S. until April or May.

That would be my guess, because once they complete the trial, then they'll do the data analysis and go from there.

You can actually look up any clinical trial that is going on in the United States on clinicaltrials.gov. And there is a link to the 30,000-person randomized controlled trial for the AstraZeneca vaccine going on in the US.

They'll actually tell you when this study was started and when the estimated primary completion date is and all that. So feel free to peruse that at your leisure, if you're curious about it. So that's what's going on with vaccines.

Supply is going up slowly, but surely. We have more vaccine candidates, hopefully, that are going to complete trials and have data forthcoming in the next couple of months. And so hopefully by the summer, we'll have both increased supply and more options out there for people.

COVID Vaccines and ITP

Now, I do want to address a question that came in through our blog again about ITP, this immune thrombocytopenia related to the vaccine.

There is a risk of developing immune thrombocytopenia from many vaccines. These vaccines are not unique in this way. Many types of vaccines — flu vaccine, hepatitis vaccine, pneumonia vaccine — a lot of these vaccines can cause ITP. And it's where your immune system gets basically bamboozled and it makes antibodies, not only against what's in the vaccine, but against your platelets, which is a critical part of your blood that keeps your blood clotting.

So what can happen if you get ITP is you can bleed and have hemorrhages and things like that. It's obviously concerning. It's a concerning side effect. It's a rare side effect of many vaccines. It seems that that's going to be the case for these COVID vaccines as well.

Now, the thing to keep in mind with ITP is that you can get ITP from viral infections, too. So COVID, flu, cold viruses, all of these types of things can cause ITP in and of themselves.

By and large, for most vaccines, the number of cases of ITP caused by the vaccine are actually less than would have occurred just from natural viral infection anyway. So I don't think that the general concern about getting ITP from the vaccine is reason enough not to get it in the first place.

Now, if you have a diagnosis of ITP already, and you already have this disorder, it's a little bit more cause for pause. It doesn't mean you shouldn't get it, but what I would say is if you do have ITP and you know you have ITP, I would talk with your primary care doctor or your hematologist and ask them whether you should go ahead and get the vaccine or not at this point based on the data that we have.

So that's what I would say about that. If you've got ITP, talk with your doctor or hematologist. I think in most cases, they're probably going to recommend that you go ahead and take it unless your platelet count is very low currently, but talk with them first, make sure that it's right for you. But in general, it's probably not a reason not to get it. But again, talk with them first, make sure.

Likelihood of More Variants

"How likely or unlikely is it that coronavirus will evolve to evade immunity from current vaccines, given the current level of infection around the world? How long might this take to occur?"

I think it's likely based on what we're seeing that eventually the virus will evolve to escape, at least partially escape, from immunity from the vaccines. I think it's going to wind up being somewhat like the flu in that way, where at certain intervals, we'll probably will have to take booster vaccines in order to remain protected.

Now, I don't think it's going to change as fast or as much as flu, just because the flu genome is a little different. The flu genome is actually kind of like a deck of cards and it shuffles itself. So it changes faster. It can become very different much more quickly than most viruses.

I don't know that we're going to lose the protection from the vaccines quite that quickly, but it may be something we have to address every couple of years or so.

CDC Guidance for Transmission After Vaccination

"What is the latest thinking on how likely it is that vaccinated individuals can spread COVID? Context: My mom and her husband are already vaccinated. How safe is it for me to be around them?"

I think the CDC has actually answered this question for us pretty pretty well, but also in a way that's a little confusing.

The CDC updated their guidance last week saying that if you've been fully vaccinated in the last 90 days and you're exposed, you do not need to quarantine anymore.

So what that says to me is that they've reviewed the data and based on some initial data that's come out from, I believe, AstraZeneca, they are thinking that if you've been vaccinated, your likelihood of transmitting it's vanishingly small ,which is kind of what we were all hoping was going to be the case.

And it makes sense, right? We just didn't know. And I think we haven't seen enough data on that yet, but the CDC did change its guidance. So if you've been exposed within 90 days after immunization, you do not need to quarantine anymore. And I think that's because you're no longer a transmission risk. They're not considering you a transmission risk at that point.

Now what's a little confusing about that is we're still telling those vaccinated people that they have to wear masks because of the risk of transmission. So we've kind of got a little bit of a two-handed message here going on.

I think the short answer to your question is I think the odds of someone transmitting it after being fully vaccinated with two doses, two weeks after the second vaccine, is very, very small. Close to zero.

So in other words, I think if you are an unvaccinated person around vaccinated people, based on what we know now, I think the odds of you catching it from a vaccinated person are vanishingly small, not zero, but vanishingly small.

Timeline for Virginia Moving to 1C

"When do you expect Virginia to complete the 1B vaccinations and move to the 1C group?"

I'll be honest. I think it's going to be a long time. Virginia is not moving anywhere near quickly enough to do that in any reasonable timeframe.

At this point, I'm thinking it's going to be summer before they get to the 1C folks. They really haven't even scratched the surface of the 1B folks at this point.

I mean, it's now mid-February, so maybe that will change if vaccine supply can continue to go up more quickly? But the vaccine distribution, it's just not moving in Virginia well at all. There's been a little bit of help from CVS having some vaccine availability, which has taken a little bit of the pressure off and allowed some people to get vaccine. But still that's only 65 and up at CVS.

So I think it's going to be quite awhile, probably summer, mid-summer, even before 1C people get offered the vaccines.

Long Hauler COVID Symptoms

"Andy says, do we know how frequently long hauler COVID symptoms occur? How big a problem is this?"

Yeah, I'm not sure how frequent it is. It's not rare. I wouldn't call it rare. I wouldn't call it common either.

I think there's probably a certain percentage of people that are going to have long-term symptoms. But I think that that's true with almost any virus, right? Flu virus, Coxsackie viruses, whatever it is.

There's a certain percentage of people that have long-term symptoms from those viruses for a whole host of reasons. We don't know why. Sometimes it's an autoimmune reaction. Sometimes it's just persistent post-viral fatigue syndrome and similar things like that. Or damage from the virus to nerve systems and other things. Or the cardiac system.

This happens with flu. It happens with Coxsackie virus and other things, rhinoviruses even, enteroviruses can do this right? A few years back, there was an outbreak in Virginia and a couple of other states of an enterovirus virus that was causing like a polio-type syndrome after infection. So these things do happen with viruses.

I think you're going to find 1 to 3% of people with COVID are going to have long-term issues after the infection. And I don't think that's all that different from most viral infections.

What I think you will find, and this is true with most illnesses too, the sicker people are, the more likely they are going to have longer-term problems. You know, people who've been in the ICU, they've been on ventilators, things like that, whatever the cause is, whether it's COVID or something else, they're going to have long-term issues and a very prolonged recovery.

So I think you're going to see a few percent of people that have long-term symptoms with this. But it's not most people and it's not even a large percentage of people. But it's, it's enough for it to be a concern.

I know VCU, and probably some other places, are starting to put together post-COVID clinics to follow these people. And time will tell, but I think you'll see a few percent of people that are going to have long-term issues from it, for sure.

Vaccinated People With Unvaccinated People

"So those of us who were vaccinated can safely be with those who haven't gotten the vaccines yet and won't have them for months?"

I think so, based on my read of the data, based on my understanding of what the CDC is saying, and based on the way we're behaving with our own family. My wife and I, we've both been vaccinated. My mother-in-law has been vaccinated as she's a nurse.

I don't think that we can really, at least for this 90 day period that the CDC is recommending after vaccination, I don't think that there's much, if any, risk of transmitting it to other people based on what the CDC said.

Consequences of More Transmissible COVID Strains

"Can you explain the practical consequences of a coronavirus strain being more transmissible? How much more dangerous are these as compared to the original? If one of those strains becomes highly prevalent, would we need different mitigation strategies or other public health interventions?"

The thing I'm struggling with this is that even with the main COVID strains that we've been dealing with, a lot of our mitigation strategies have not been very effective period. Now whether that's because they've been applied inconsistently, people aren't doing it, whatever, the strategies that we've been doing, haven't worked all that well.

So, you know, I think short of locking people in their homes, even more strictly than we did in March and April, I'm not sure that the current mitigation strategies are making massive differences.

And I think if you add on top of that these more transmissible strains, I'm not sure that the current strategies are going to make a difference at all, but I don't think doing anything short of locking people in their homes is going to make a difference with these more transmissible strains at this point, unfortunately, because they are so transmissible.

That kind of leaves us in this weird spot where we're kind of back to this original question that we had back last March, last April, with are the lockdowns worth the costs?

I think that's really the big question. I think to avoid that question, which is what we want to do, we want to avoid that question altogether, is to just get the vaccines out as fast as possible to everybody who's at risk and get ahead of these transmissible strains.

And that's why I've remained so frustrated that the vaccine rollout has gone so slowly, because I think if we don't roll out the vaccines and these more transmissible strains become dominant, which they will inevitably become dominant, we're going to be back faced with this question about stringent lockdowns again when it was avoidable. And I think that's my issue with that whole thing.

Quarantining Again After 90 Days While Vaccinated?

"Vaccinated within the last 90 days, so after three months of immunization, we need to start over and start quarantining again?"

That's the official guidance from CDC right now. I suspect what's going to happen is they're going to keep releasing updates to that guidance as they get more data. I think when we get to 90 days, say, from now, they're going to change the guidance and say, well, it's probably okay if you do six months based on the data. And they're going to keep expanding that out, because I think the reality is that most vaccines are good at preventing transmission, and there's no reason to suspect this one would be different. So I think they're going to keep updating that.

Significance of the 90 Days

"Would you explain the significance of the 90 days that you mentioned?"

That's what the CDC decided based on the data that they have. And I think it's meant to coincide with what they have found to be a low risk of reinfection for people naturally immune after they've had the first illness. There's almost no cases of reinfection within 90 days of the primary infection. So I think where they got the 90 days from there. So that's how they came to that.

Antibody Infusions for People With COVID

"Have you talked about infusions for people who get COVID?"

I'm guessing you're talking about the antibody infusions. We recommend them. They're only available to people who meet certain criteria, so they have to be higher risk. You sort of have to be at risk of getting really sick, but you can't actually be really sick to get them.

So older people with risk factors who currently aren't having problems with oxygen levels and things like that, you can get the infusions in most places.

We are generally recommending people get the Regeneron infusion. That seems to have the best data. It Is a bit of a process to get it. You have to go to a local hospital and get it done in an infusion center. But it does seem to help based on just our anecdotal sort of reports on the patients that we have had use it.

So I think they're good to use. I think they're safe. And the one thing to keep in mind is if you get an infusion like that for a COVID infection, you cannot get vaccinated for 90 days after that, the antibody infusion.

Second Dose Needed After Mild COVID Case

"Do you need a second vaccine after the first if you had a mild case of COVID prior to receiving the first vaccine?"

Yes. FDA and the manufacturers and CDC all say you need both doses even if you had a COVID infection at some point. So yeah, that doesn't change the number of doses you need.

Now what we are seeing, and just so you're aware, is that it seems to be, and I don't have any data to back this up other than what patients have told me, it seems to be that people who have gotten COVID and been sick with COVID and then later got the vaccine are having a little bit of a stronger response to the vaccine in terms of side effects. Not feeling well, body aches, chills, fevers, that sort of thing, which makes sense, because your immune system's already partially primed from the primary infection.

So just something to keep in mind there, but you still do need to get both doses of the vaccine according to all the recommendations.