Fielding COVID Questions

I haven’t written a COVID blog in a while (too busy chasing my toddler). But I’ve been fielding the same COVID questions from people, so it’s maybe more efficient to put it in writing. First, I thought it would be worthwhile to examine a tough question I received in February 2021, more than year ago. Back then, vaccine was just beginning to roll out and the end of the pandemic was in sight. I was asked to project what life would be like in 2022. Did I miss the mark?

Hi Martha, I hope you’re well! I have greatly enjoyed and appreciated your posting about the pandemic since the spring. I wanted to reach out with a few life updates as well as a question. I graduated from medical school last spring and started my internal medicine training at XXX College of Medicine, and I am loving it! I’m considering cardiology or GI fellowships post-residency, and I’ll be starting cardiology research in the coming weeks. On a personal note, I got engaged about a year ago! XXX (my fiancée) and I have begun wedding planning in hopes of getting married in 2022. We are considering options ranging from May to August for 150 people in NYC. That is where my question comes in. I know no one has a crystal ball and that modeling cannot perfectly capture reality. From a COVID perspective, do you have an opinion as to when is the beginning of an appropriate time period in 2022 to consider having an event that would be indoors for approximately 150 people? We have an option for May 28th that we are considering and also are looking at August 20th. Do you think end of May 2022 is too soon? I am wondering if you think pushing the date to August is likely to significantly decrease any COVID risk? I recognize it’s hard to give answers to these questions, but I felt that getting the opinion of an expert could really help us decide, and I value your opinion. Thank you very much for your any thoughts you may have. I know I owe everyone a more thorough update, but please say hello to everyone from me! All the best, XXX

Hi XXX, It’s great to here from you! Congratulations on….EVERYTHING. You can imagine I get these questions a lot. The big unknown is variants. We can get America’s adults vaccinated by 2022. But could there be a new crop of variants in 2022 that are not as well protected by vaccines? We’re kind of setting the stage for that to happen by having a partially immunized population and a UK highly transmissible variant rising fast that could led [sic] to large numbers of infections in a population with incomplete immunity and strong selection for immune-escape variants. Without a crystal ball here’s how I’d lay out your options: Option 1: Outdoor wedding. Option 2: 50 person wedding. Option 3: 2023 wedding.

I don’t know if my friend took my advice on his 150-person indoor wedding or not. I know the answer I gave him was not the one he wanted. But I know that my mom got infected during an outbreak at an indoor wedding held during spring of 2022 (she’s fully recovered now). The “UK highly transmissible variant” I referred to was alpha, which never caused the massive wave in the US that it did in the UK, but was a harbinger of the delta and omicron variants to come. But I understand where he was coming from. Back in February 2021 most Americans believed the pandemic was essentially over once they got the vaccine in their arm. No one understood why I wasn’t so convinced. In case people are curious what my predictions are today, here are some of the other questions I’ve been answering these past few weeks.

Question: The CDC 5-day isolation rule is confusing. Back when it was 10-day isolation you could be pretty confident that if you “did your time” you were no longer infectious and could go back to life as usual (whatever that is now). Is that still true? Why the shortened isolation? Did the virus really change that much?

Answer: Yes and no. Yes, omicron behaves differently from the original strain. It’s a supercharged virus that replicates really fast, so the timeline of infection and transmission is shorter. But it’s not half. The 5-day isolation period is also a practical compromise with an American economy desperate to get back to work so the trains can run again. The CDC did not state that no transmission occurs after 5 days, only that the *majority* of transmission occurs in the first 5 days. The CDC watered down the policy even more by saying that you needn’t be symptom-free after 5 days, you just needed to have symptoms that were “resolving (no fever within 24 hours.” The CDC also did not require people to test negative before returning to work. They tried to make up for these shortcomings by asking people to mask up for another 5 days (so 5 days isolation + 5 days mask). But this is a pretty leaky set of recommendations.

The upshot is that it’s much easier for Americans to go back to work after a COVID infection, but they’re much more likely to infect other people. So on the plus side, America, if you get infected with COVID, it’s not the 10-day stranglehold it used to be. But on the downside, America, you’re much more likely to encounter still-infectious people wandering around your schools, airline terminals, churches, etc. Is that a good tradeoff or a bad one? You tell me. Practically speaking, if you get infected with COVID, you can still follow the CDC’s 5-day isolation period, but after that don’t just slap on a mask and go back to life as normal (definitely don’t go visit granny at the nursing home). If you still have symptoms, even mild, stay home. Tests aren’t the panacea we once thought they were, but they can give you some indication of whether you’re likely to still be infectious, especially if you test negative multiple days in a row. In the end, just know that you could still be infectious after 5 days and proceed with caution. After 10 days and some negative tests, you can probably relax.

Question: About that “relax”…..at that point I’m like a superhero who can’t get reinfected for at least a few months, right?

Answer: Remember those pesky variants I mentioned back in February 2021 to Mr Wedding? Houston, we still have a variant problem. Omicron is not a single variant, but actually a family of 5 different variants (BA.1-BA.5). If you were infected this spring or early summer you were probably infected with BA.2. Now BA.5 is quickly on the rise and beginning to dominate. Most of the studies done by scientists have been on the BA.1 and BA.2 variants, so the newer BA.5 are not as well characterized. But early data suggests there could be substantial risk of reinfection with BA.5 among those infected with BA.2. The upshot: a period of invulnerability post-infection could be a myth.

BA.5 on the rise in the mid-Atlantic region

Question: Why did it take so long to get the vaccines for young kids approved? Are they safe?

Answer: Vaccine manufacturers like Pfizer knew what kind of volcano would erupt if they made an errors in the kid vaccine. Even if just one kid got seriously ill in clinical trials it would be game over. The wave of vaccine hesitancy made them even more cautious. So it’s understandable why they started their trials with a really low dosage in the under-5 vaccine (3 micrograms, whereas the adult Pfizer dose has 30). Pfizer erred on the side of caution. Well, it turns out they erred a little too far. The vaccine barely made a blip in antibody response. So they had to go back and add a third dose. But the third dose was given 8 weeks after doses 1 and 2, meaning it takes 3 months for a kid getting the Pfizer vaccine to be considered fully vaccinated.

The Moderna under-5 vaccine has 25 micrograms in each shot (the Moderna adult vaccine has 100). When I had to make a personal decision about my own vaccination, I opted for the more potent Moderna vaccine over Pfizer. Moderna does appear to have longer-lasting immune protection than Pfizer.

It’s understandable that American parents are confused about the differences between the Pfizer and Moderna vaccines, the different dosing schedules, and skeptical of a vaccine that seemed to have a number of false starts. But I consider it a good thing that parents have options. Those, like me, who want to get their kid maximally protected in the shortest time possible, can opt for Moderna. Those who are more cautious and prefer a lower-dose regimen over a longer wait-and-see time window can choose Pfizer. This is America, and we have both Coke and Pepsi. The math is pretty straightforward that 2 doses of Moderna (25 + 25) is still much higher than 3 doses of Pfizer (3 + 3 + 3). Like the adult vaccine, the Pfizer vaccine will still protect, but that protecting might wane more quickly.

Speaking of my kid, I need to go pack his lunch pronto! Let me know if I missed any burning questions. We didn’t even get to international travel yet.

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