From primary care providers to subspecialists who see immunocompromised patients, medical professionals are facing a barrage of vaccine questions. George Rutherford III, MD, who leads UCSF’s infectious disease division, provides a comprehensive brief to arm you with answers. Covering vaccines currently in use and those on the verge of approval, he breaks down vaccine types; addresses fears about side effects, such as blood clots; and discusses managing virus variants.
Thanks very much. It's a real pleasure to be with you today. So, I was gonna talk for 10, 15 minutes, just kind of give you a brief overview of the vaccines and kind of what? So Karen, and then get into the questions. So when we came, when it came time to develop vaccines for COVID-19. There are four basic uh four basic approaches. One or genetic vaccines which have turned out to be the real home run here. These are RNA or DNA vaccines. Then they're vectored vaccines, meaning typically using adenovirus vectors. That's what johnson and johnson and astrazeneca has. We've never had a genetic vaccine before but we have had one approved vectored vaccine which is for Ebola virus. Probably don't give it much in your clinics. We have protein vaccines and that maybe the next one down the line, for example, of a recombinant protein vaccine is uh human papilloma virus vaccine or hepatitis B vaccine. And then we have inactivated or attenuated vaccines, which is Basically 1920s Technology. This is you can see the kind of pipeline here. There are six vaccines that have been authorized, at least in some countries and aid have been approved for full use in some countries in the U. S. We have three authorized but not yet fully approved vaccines. The MRNA vaccines are as they as they say, there's a a coated particle, a lipid coated particle of messenger RNA A uh that's injected. It's picked up in in the cells where it's transcribed in the cytoplasm. This never enters the nucleus so it's not incorporated into the nucleus. It makes a spike proteins that the spike proteins are extruded and their antibodies made to those spike proteins. When you have an immune response, B cells will recognize those and present them to help her T cells which will start the immunological cascade. The other is adenovirus. Adenoviruses are are are sorry our DNA viruses. And so what we've inserted is a piece of basically reversed trans reverse, fully transcribed R. N. A. Into the DNA of the adenovirus and have taken out the replication jeans for the adenovirus. These get picked up incorporated into the nucleus inserted into the host genome. And basically what it makes is M. RNA. For the spike protein, which is transcribed and uh and extruded, causing the immune reaction. So this does get into cell walls. But it's the adenoviruses are deficient. They don't have the enzymes they need to replicate. So this is the list of the of the approved and or authorized vaccines. The ones we have are the Pfizer biontech Mrna and the Moderna Mrna. And we also have the johnson and johnson adenovirus vectored vaccine, europe is extensively using the Astrazeneca vaccine along with Pfizer and Moderna. Um and to a certain extent J and J. Other countries are using the γ Leah vaccine. This is called Sputnik five. And the Sputnik vaccine is not only used in in Russia but also extensively in latin America. As is the can sinovac vaccine, which is a chinese vaccines. Some of these other things coming down the line you can see here uh and Novavax which is a protein vaccine. A recombinant protein vaccine may in fact be approved this summer. Here are the three that are approved in the for the for us use plus Astrazeneca which has been approved in both europe Mexico and Canada. Um This is uh with the exception of the J and J vaccine, these are all too does vaccines that are given with specified and specified intervals. Um Their efficacy, trial efficacy for preventing The disease. COVID-19 is 95 for the fighter, 94 for the Madonna, 72 for the J&J vaccine, which is in a really fair comparison because this was done later after the emergence of some variance and 76 for the uh for the uh astrazeneca. Here, you can see um that this is protective against the common variants. This is the UK variant. This is the Brazilian variant. This is the South african, a variant. It's also seen clinical benefit in Israel against the B 117. This is likely some protection against common variants, but more data are needed and the J and J has has had lower efficacy. There are large numbers of patients in the original trials from brazil and South Africa. But as you'll see in the next column over All of these, all four of these are 100 protective Against death and hospitalization. That is. There were zero deaths and zero hospitalizations due to covid in the vaccine arms of these trials. More recently, we've developed data to examine effectiveness now by efficacy. These are this is inside baseball stuff in epidemiology by efficacy. I mean, clinical trial, how well they perform in clinical trials by effectiveness. That's how well they perform in real life. Uh This is a uh looking both at Pfizer and Moderna vaccines and um 24 cohorts of of hospital of of health care workers. And this as an endpoint of hospitalization With full vaccination, there's 94 vaccine effectiveness With partial vaccination, there's 64 effectiveness. But there is a you know, if you can't get out 14 days after the after your second dose you essentially have no protection. So that's the window we're dealing with. These are other data. These are from SAn Diego and Los Angeles from U. C. San Diego. And I think this was harbor General Hospital. Uh so let's talk about dose to hear if your day 15 or later. There are seven out of four out of 4167 people who are who are in this group. We developed disease. This is about a one in 500 sort of round number. Something like that. Little bit, little bit uh more than it's more like one in 600. Um here in Dallas, Not here in Dallas in Dallas. And this is at south Ut southwestern. Um, you can see that this the employees with Covid, There are four of 8 8121. So this would be like .5%. Okay. CDCs recently published its vaccine breakthroughs. But let's look over here in the trial. So in the modern a trial In the vaccine in arm, there are 11 out of 14,000 people who received vaccines. That's one for every 1285. And the fighter trial was one for every 27 17. And in the J. And J. Trial, this is overall not just in the US, this includes South Africa and brazil. It was one in 292 by any stretch of the imagination. These are huge, huge, hugely beneficial. The CDC just reported 5800 cases of vaccine breakthrough, meaning 14 days after the last dose, a PCR PCR positive infection. So they have 50 800 out of 66 million. Uh and that's a rate of one and 11,000, which is about 10 times lower than these rates. So you can get an idea that there's probably some undercounting. 40 of these were in people 65 years and older. They did not put out denominators with this. You gotta figure that since most of the early vaccines were older, except for health care workers, that this problem this may or may not be disproportionate, 65 were in women. And interestingly 30 of these were asymptomatic. There are seven are hospitalized and there are 74 deaths in this group, most of whom are very elderly and in nursing homes. Um If we look at the different variants, the UK variant of South African, The two Brazilian variants, uh This is a new wrinkle that's just come out the E. 44 K Mutant. And then this is the UK plus the 40 44 K mutant. If you say this is what we this is how much uh we need to uh to neutralize the wild type virus. You can see you have you need more To neutralize the b 117 and the Astrazeneca really. So it seemed not to perform very well. But you have to realize that you have probably have your typewriters of neutralizing antibody Probably something like 17 fold higher. So 10, you know 10 needing tenfold. You're still kind of within the range for the P. 1 30 P. 1351 the South African variant. Most of the Madonna Pfizer ones are kind of in this, you know, you need more but you don't need that much more. The astrazeneca one is way out of line and this is about probably meaning 44 40 fold more. And South Africa stopped giving astrazeneca for the P. One variant. It's kind of mixed there two studies, one where it's susceptible And one where it's not and so on. And the e 44 K. and adding that to the b 117. Those are all within the susceptible range. And the two variants we talk about in California, the B 14 to 7 and the B 14 to 9 have about a three fold increase in three fold reduction in neutralization activity. Now this is all due to this guy here. This is the spike protein and this is the the binding site from the from the cell surface of the of the target cell which are epithelial cells, respiratory epithelial cells. And you can see these mutations the 484 K. The K 44 17 en and the en 51 Why these are these red dots here. Right so they're at the edges rather than these mutations here that are right in the middle of the the binding site. These mutations are at the edges. If you're right in the middle, you're probably just going to kill the virus off, it's not going to be able to attach just school's out. But if it's here at the edges, um you may mess up the antibody binding without messing up the ability to bind to the receptor. So if you want to think about this geological Nigeria, geologically geographically, you're looking for mutations that are sort of at the edges of the binding sites. And this is all up here on this, the face of this receptor binding domain now in California. Um I have been for a long time saying we're fortunate because we have these West Coast variants or California variants Which are about 20 more transmissible but are not 50 more transmissible, like the UK variant that looks like that advantage has gone away and we're starting to see either county by county sort of the roughly similar proportions of UK and California variants. This all has to add up to one. So it's a bit artificial. But these these are the actual numbers are very low but the proportions are higher. So I think we may be seeing kind of there the gradual replacement of the California variants with the UK variant, It's not the end of the world. Well, the vaccine works against the UK variant and we have a lot of people vaccinated and we have a lot of people have naturally acquired immunity. So we may be out in front of this. So some considerations for future variant emergence. The lower the transmission rate, the lower the emergence of variants will be if the virus isn't replicating, it can't mutate. Um The other thing is that, well, you know, our solution is to vaccinate everybody understand that creates selective pressure and you may have escaped mutations that will have to deal with when if and when those happen. But I think for now the general public health approaches to push for vaccination, try and get as many people vaccinated as possible with an eye towards towards her immunity which will result in lower transmission and the protection of immuno compromised individuals by the herd. We can vaccinate immuno compromised individuals. That's no big deal. But if they get but it may or may not work very well in them and if they get sick, they are the ones that have prolonged carriage of the virus and well and are probably the source of many of these mutations that we're seeing. So when we think about vaccine failure, this is not all about variants, the main reason for vaccine failures that people mishandled it, they allowed it to defrost. They didn't do it right. You know, they stuck the needle through the arm and into the sheets, you know, whatever. But it's, there's mishandling is the real reason for most vaccine failures in real life, immuno compromised in essence of the immune system. Those are real reasons as well. There are some therapeutics like toast uh socialism, oB, which is a memory. It was a b cell blocking agent monoclonal antibody, which will mess up the vaccine and then finally, the variants that may or may not be as susceptible at all. Very few, if any or as susceptible, several as the wild type vaccine. But the real reason we see outbreaks, his failure to vaccinate and that's what's going on in India right now, With only five of the adult, five or six of the adult population vaccinated. So when we see failures don't instantly spring to saying at the population level that this represents vaccine failure. It more often than not represents failure to vaccinate. Just a couple of words about intentions. Um, this looks over time and keep your eye out here On these two together, 24%, 2022, 20 percent, only if required are definitely not. So we can get to 80 of people I think pretty pretty well. Uh, the other thing that's going to happen is next monday, probably the FDA is going to extend the emergency use authorization Down to 12 years of age. So that will create more pressure on the vaccine delivery system. And I think one of the things that you're going to see is that people in this group here Are not going to be able to do things. So if these are 20 year olds or 22 year olds who say this is a problem taken care of. Why should I be bothered? They may not be able to go to the movies. They may not be able to go to a ball game. They may not be able to go in two restaurants their life maybe controlled by a lot of nasal testing for virus before they're allowed to do things. So they may tip into the camp of getting vaccinated. Okay There we have that. So the 39 questions sounds like an Alfred Hitchcock. 39 steps was a 39. Okay so I'll come back to these after we I'll come back and answer questions after we're done. How safe is the COVID-19 vaccine for pregnant women? What are the current recommendations from CDC and ACOG on pregnant women getting the vaccine? So what C. D. C. And a cock say is that pregnant women can get the vaccine? They don't say should they say can the way I think about this is that you want really really really want to vaccinate women in the third trimester So that there can be passive transfer of antibodies and we can protect young Children out 6-9 months of age as a pediatrician. I'm somewhat of a leave well enough alone person for first trimester therapeutics. Although a cock doesn't differentiate that. What I think I'd really say is if you have a patient I was planning on pregnancy I would tell her to get vaccinated now before she comes pregnant becomes pregnant and doesn't have to face these uh these questions. The second question is what did the efficacy rates of each vaccine mean is J. And J. Vaccine less effective. So I love how he flipped from efficacy to effectiveness in the middle of this question. Um So the efficacy rates are, it's basically the attack rate and the unvaccinated minus the attack rate and the vaccinated divided by the attack rate and the unvaccinated. So if the attack rate in the vaccinated people is zero, you have Attack rate and vaccinated zero divided by attack rate and vaccinated. That's one or 100 effective or efficacious. Depending on if it's a trial in real life, if you have something that's uh where the attack rate in the people who have been vaccinated as half of what it is and the people who have been unvaccinated, the vaccine efficacy ease 50%. So you can see how that, how that works. Um, Don't think of this is that if you give somebody a vaccine, they have a 10 chance of failing. What that means is if you line them all up and squirted virus up their noses. Yes they would have a 10 risk of developing disease. But the development of disease not is not only about immunity, it's about risk of exposure. So if they're given that we have very low transmission here currently in the in northern California and given that people are pretty compliant about wearing masks and avoiding situations in which transmission can take place. You saw what the US. data where it's one in 10,000 was what they were saying the the failure the breakthrough rate was which is all kind of part and parcel of the same terms. So it's a function of exposure as well as uh how well the immune system response to the vaccine. There will be people who do not respond to it. There'll be problems with mishandling. There will be other things that go on that may lead to their maybe therapeutic uh interference by certain drugs uh that that may make it make the immune response less robust. But the bottom line is if they're not going to get exposed to the virus, they're not going to get infected, isn't third? What's the clot risk of each of the vaccine? Should I be concerned? So the clots have been reported with all the vaccines. Um but in the modern and the fighter trials, they seem to be no more common than clots in the population in general. These these platelet rich uh these these uh platelet clots that are associated with thrombosis, Dapena in these sort of gelatinous platelet clots which is called vaccine induced Rambo side of panic, thrombosis a visit or seem to have the same mechanism of action as heparin induced, thrown beside a pina or its variants spon to hit or it's it's very spontaneous. Heparin induced homicide opinion which no one will touch with an acronym. Um And that's a uh that's the same mechanism that occurs in the absence of heparin. This involves platelet factor four which gets unmasked somehow and leads to the clotting cast skate. It's treatable with I. V. I. G. And steroids. It's not treatable with heparin. And that's in fact the mistake. These have presented mostly with cerebral venous thrombosis. Not cavernous sinus but cerebral uh cerebral sinus vein thrombosis but also uh D. V. With deep vein thrombosis in the in the lower extremities and in the abdomen you should be concerned. But the risk is about one in a million. And I'll show you some more data a little later about the Johnson and Johnson one specifically. How effective are the vaccines related to the new and different variants? I think I've touched on this. Uh the astrazeneca one against the South african variant. No boy, no good. Ah The others seem to have at least partial effect. And the British who have all be 117 variants have controlled their outbreak with Astrazeneca vaccine. So it gives you an idea of how well that vaccine works against the B117 variant. And our our thought is that the current vaccines Moderna Pfizer and J and J. Will work well against the against the UK and the California variants. One of the most common side effects for each vaccine. Well, you have basically have interfere anemia Especially after the 2nd dose. Some people say that the first doses about B cell immunity and about human immunity and the second dose is about cellular immunity. So you get federal and chills and aches and pains and feeling flu ish. Um That's some people get nauseated. That's not at all unexpected. It may occur in as many as 60-plus of people getting their second doses and I know the police forces at least here in the East Bay when we were, when they were getting vaccinated, gave everybody a day off the next day. The other thing is you can get uh collateral axillary lymph at an apathy. Uh and that goes away over time. That's just a sign of things revving up. Okay, what's the likelihood of needing a booster for each vaccine? Well, there are two things here. One or booster doses per se to increase your levels of immunity and the other is trying to broaden the base of immunity like we do for influenza vaccine with influenza vaccines each year. I think the need for boosting per se to try and increase the levels of what's currently in the vaccine. I don't think we're going to need those. What we may well need our is a broadened um a series of Spike protein spike proteins. Part of that like the South Africa and one and maybe the Brazilian one. Maybe the UK 1 to get broader immune coverage. I don't think we're going to need more. Higher. Um Okay, how soon do you think we'll have to have a booster vaccine? Uh you know the the president of the Ceo of Pfizer, the early in April said that he thought we need one between six and 12 months. You said likely likely beware adverbs. I think it's I think that's unlikely. And I think you know, we'll be we'll be having this conversation In the fall of 2022 about whether it's time to broaden the level of immunity. I think we need to concentrate on getting everybody vaccinated first. Is there any reason as to why you would not get vaccinated? Yes, there is one absolute contra indication which is an awful access to the first dose. If you've anaphylaxis to the first dose, you should not get to the second dose. If you have an Ifill acts to any of the components, the first dose and good luck figuring out what those are. It's mostly something called polyethylene glycol um which is a base and cosmetics among other things. Um uh if you've anaphylaxis to that, although I would never know how you figure that out. Maybe immunologists can figure it out. Um biologists can figure it out, then you should not get vaccinated. But that's the one absolute contra indication. People who have history of anaphylaxis to various and sundry mids. Our uh the discussion is get vaccinated in some place you can treat you uh and they can treat you for anaphylaxis e not a pharmacy and stay a little a little longer to make sure. Um There is a school of thought, mainly european school of thought. The people who have been previously infected with naturally acquired disease May not need a 2nd dose. I think schools out on that, the french have gone down that path, but it may be mostly about saving vaccine. Um But well I think school's out on that and we'll have to keep following for right now. Um I think clinically what I tell people who ask me is if you've been vaccinated um If you've been previously vaccinated, I'm sorry if you've been previously infected and you've had a bad reaction to the first dose, I might call it quits then or at least wait a while before even longer before you get a second dose. There's no science behind that. But it's a kind of a risk avoidance thing. What if you get you can get your second vaccine in 21-28 days is it's still effective? You are the winner. The 21-28 days is a minimum interval. It's actually three days less than that. It's 18-25 days. That's a minimum interval. These things work much better if you can get them a couple of months apart, six weeks apart. So if you can't get it and the reason the timeframe is compressed was to try and get as many people vaccinated as possible. So don't worry. If you can't get it Uh exactly 21 or 28 days, you'll probably even get a better immune response if you wait a little bit longer. How long does it take the vaccine to work? It takes fully two weeks after the after the final dose for J and J. Two weeks after a single dose for modern Advisor, two weeks after the double dose. What happens if you get covid between your two doses? Well, I guess the first one didn't work. The Madonna has quite a bit of activity against covid after a single after a single dose Pfizer less. So um if you get this then I think you would probably come back again at some eventual point in time and get one more dose. Just because we're not sure quite how long naturally acquired immunity last. This is not a vaccine failure. Um You just happened to bump into covid while you were getting vaccinated. This is an inter current infection. Do I have to pay to get a covid vaccine? Not in this country. You don't? So that's good. Ah What's the update on the J. And J. Vaccine is it's safe? Well to find safe. So these are the slides that were shown at the C. D. C. S. Advisory Committee on immunization practices meeting. We could go friday. Um and among women 18 to 49 They thought they would see 13 cases of this is the same thing as as V. V. I. T. T thrombosis with rama sita pena syndrome. But on the plus side that would prevent 12 deaths. 127 icu admissions And 657 hospitalizations Due to COVID 19 Among women over 5050 and over There'll be two cases but there'll be 539 deaths prevented 1292 ICU admissions and so on. But look at this 12 versus 13. Uh huh. Among men, it's two versus 11 114 601 and then among older men, there's essentially no risk. There've been no cases reported. So what the way A C. I. P N. C. D. C interpreted these data was to say that people should be advised that there is a rare risk of these occurrences of this Tts syndrome, orbit syndrome. Uh and that they should make an educated. Uh they should make they should be able to opt out of receiving the J and J vaccine in favor of a different vaccine. I personally think this is pretty close, pretty close call and I've told my four adult daughters to try and avoid this, avoid getting J and J for just this reason. How long does protection from Covid vaccine last? Well, the first shot went into an arm last april as part of phase one trial and I'm happy to report that That 13 months later, it's still working. So um we just we don't know I mean you know this is not about antibodies. The immune system doesn't work by building up huge antibody levels and and having them circulate in your blood until you need them. The way you know otherwise your blood would be sludge with antibodies right? The way it works is that you have an antibody response That wanes and most Syrian proteins have a half life of about 120 days. And then it'll clear but you leave behind memory B cells and memory T cells that can recognize the virus, the spike protein specifically if it if it reappears. So I think you probably get quite long lasting protection. But the question is how well does it cover whatever the next strain is? So this is a not a problem. Not a question of how, what long will it last? Although that is a question. The real question is how broadly will it protect you if I had to do, I need to wait to get a vaccine. Um, I'd wait a couple of months. CDC says wait three months. But basically that's go to the end of the line. We don't need to worry about you for a while. Um, I'd wait awhile and get a vaccine tonight spoke earlier about the question about, do you get a second dose if you've already been infected? And we're motoring through these questions. Ah, If I currently have Covid, can I get a vaccine? Leave it alone. Just get better and we can we can have a conversation two or three months later. If I had Covid and recovering, I still need to get a vaccine. Yes. You do need to get a vaccine whether you need to or not. As a kind of an open question and then give it a little time between your recovery and when you get re vaccinated. I don't know if you guys have heard this or not, but there's a school of thought that people have this long Covid syndrome, this uh kind of this kind of brain fog and aches and various aches and pains and and fatigue. If you vaccinate them, they get better. I think that might, you know, which that would suggest is that there's a some sort of sequestered nest of replicating virus that's causing disease. And then if you give them vaccine, you can you can kill off that nest of viruses. I don't know. That sounds like an awful lot like comic book physiology to me. But it's um you know, there is a there is a school of thought and that's an easy thing to study in a trial. And I imagine those trials are being organized now. Uh if I have an underlying medical condition can I get the Covid vaccine? Yes absolutely positively. However if you are an immunosuppressive therapy there are some issues about the timing of immunosuppressive therapy. You don't want to get your six monthly dose of methotrexate and get vaccinated to a week later because it's not going to work it's going to blunt the immune immune response. So there's some timing issues here. The european um what's it called? The european, rheumatology, associate rheumatology society or a society for rheumatology has guidelines on this for a whole variety of vaccines including live virus vaccines, about how to how to um basically time immunosuppressive therapy and vaccine delivery. Um This thursday U. C. S. F. I guess that's two days from now. UCSF grand rounds are going to be around covid and the immune system in the immuno compromised. And will include a discussion of of uh vaccination of people with immuno compromised. But when they when people tell you I can't get vaccinated because you know I live at home with somebody who has colon cancer. That's a reason to get vaccinated. Right? You don't want to be you know you don't want you don't shed virus when you're vaccinated. This isn't polio like polio virus or oral poliovirus. You don't shed virus when you're vaccinated, you basically are protected and you don't shed virus. And if you uh and you cut down your risk of of of uh of disease enormously. So if you want to protect people at home you need to get vaccinated and they need to get vaccinated too. What are the chances of getting covid after the vaccine I showed you the U. S. Data? Current suggestion is One in 10,000 California data right now and they match all the registries. It's about one in 5000. And in the trials admittedly a lot of the trials were done during surges of infection so there was a lot greater exposure to disease. Um It was more like in the one in one in 1001 in 2000 range. Ah Do I still need to wear a mask? If I have received both doses? We want to read a completely confusing set of guidelines. Read the C. D. C. D. C. Guidelines about this basically it says if you're outside in your family pod or by yourself you don't need to wear a mask or if you go inside you do need to wear a mask and then there and then there are exceptions. So it uses words like small and large without defining what a small gathering is or what a large gathering is. I think that it's lot basically. Um, If you receive both doses of vaccine Andrew two weeks out, remember that part. You don't need to wear a vaccine outdoors unless you're a big mass crowd event, like a baseball game or something. Can you spread covid if you're vaccinated? Um, the answer is uh, no in the way you're asking the question, but there is a scenario you can imagine where someone is a vaccine failure. One of these one in 10,000 or one in 5000 and they get infected people who get second people who get infected post vaccination, a lot of them are asymptomatic. And if you're asymptomatic, yes, you can spread virus but probably at fairly low levels. You'll have lower plasma about your lower viral loads in the nose and respiratory tract. And you're probably a little less infectious. But you can, if you get infected post vaccination again, one in 10,001 in 5000, yes, you could potentially spread it. But again, this is not oral polio vaccine. You don't take this home and shed virus everywhere. That's not how it works. Are any side effects from the covid long term side effects from the covid vaccine. Well, aside from cavernous sinus thrombosis, No, I mean, aside from the clots, uh, not really. Um, you know what you have to, this is why vaccine manufacturing is such a fraud business. Um, if you vaccinate everybody in the population with the vaccine, anything that ever happens to them afterwards is going to be blamed on the vaccine. Everything from autism and Children too. You know, everything else under the sun. Um, I think there might be some connections between, um, you know, if you give you have a, you know, a jolt to your immune system from a vaccine and basically turn it on. Certain things might happen in Israel. They think there may be a connection with herpes zoster recurrences, but I don't know, it's just not, it just really hasn't been reported. So the clots are one thing to be where there's also been a lot of discussion recently about dismantle area and dysfunctional uterine bleeding as a as a consequence of vaccination. Again, I think that they're in the absence of good data to take relatively common symptoms and ascribe them to the vaccine is a, I think it's unlikely to be to show causality. I'm not saying it can't happen, I think, but it has to be carefully looked at. Yeah, it's totally okay for people living in the same house to get different brands of the Covid vaccine. That's fine. I have absolutely no idea what my wife got. I think about it. We need to stop any of my regular meds before getting the vaccine. It depends on what your regular medications are. If you're highly immuno suppressed, for instance, you have mixed connective tissue disease or something like that, you need to talk to your rheumatologist about how to time dozing of medications and the vaccine. But for other other kind of regularly administered meds, the answer is no. If people are getting steroids like they're an asthmatic or something, I think that's probably something to discuss as well. Although I can't imagine that glucocorticoids would uh, that the doses that we're talking about for asthma, safer pediatric asthma would really blunt this very much. All right. How long have my vaccine immunity last? Hopefully for a long time again. We just don't know it's lasted for a year. Corona vaccine necessary. Yes, it is necessary. This is a disease with a compared to things like influenza with a high fatality rate. We've had More uh more than 600,000 fatalities in the United States. Excess fatalities in the United States from coronavirus infection. Those are not all in frail elderly. They're uh they're across the board. This is the most deaths we've had in the United States In this compressed period of time since 1918 1919, When we had 675,000. And we may approach that number. Although the U. S. Is three times bigger now. This is more than all the combat deaths in World War Two. So this is a serious, serious, serious disease. The way we have the means to protect ourselves through both non pharmaceutical interventions like wearing masks and social distancing. But that comes at an economic cost because businesses have to close to accommodate a lot of those restrictions. And we have a straightforward solution which is to get vaccinated. And we can we can despite what the new york times says, we can achieve herd immunity especially on a regional basis in the Bay Area. I'm trying to get pregnant. Should I get a covid vaccine? Uh what I would say is get vaccinated and then try and get pregnant. I think it makes a lot of sense to get vaccinated first and then uh and then uh try to get then try to get pregnant. That will you separate this sort of, you know this choice of get vaccine in the first trimester. Sure, not just just don't don't put yourself in a position to make that choice get vaccinated beforehand. Yes. You can still get vaccinated if you have uh if you have a cold I I can't remember I got vaccinated Kaiser, I can't remember all the things they asked um about sort of things they wanted to make sure we weren't in place. One of the things they did ask was have you been vaccinated with something else in the last two weeks? And that's really just to kind of be able to separate out the side effects and that's more of a housekeeping kind of thing. But yes, you can get vaccinated if you have a cold. Um So if I'm taking any of these types of medications, antibiotics, biologics, antivirals, can I get a covid vaccine? Antivirals, yes, there are some early suggestion that produce inhibitors might have some effect against covid. But we're talking about Mrna here, we're not talking about whole viruses except, well, we're not talking about whole viruses. The one thing is if you've gotten monoclonal antibody, because you've had Covid and you've got treated with a monoclonal and a body like bam, bam, bam, bam, live a man. Them little dad map. Um You're gonna have to give it time that time to go away before you get vaccinated. But that's the one thing I can say. And um the anti inflammatory drugs that rheumatologists give up, I have food allergies or medications. Should I get a covid vaccine? Yes, you should get a Covid vaccine. If you've had anaphylaxis, you need to tell the person, you need to make sure you get it in a place that can treat you like. So in the hospital um rather than in a pharmacy, uh and you would wait a longer period of time After you've gotten even. We'd be absurd for a half an hour rather than just 15 minutes. I heard that steps were skipped to make the vaccine more quickly. Is that true? Yes, it's true that what was skipped where all the proprietary intellectual property legal pieces because the U. S. Basically bought up all the you know paid all the bills. Um So from a biological standpoint absolutely nothing was skipped. Absolutely nothing from a legal regular from a legal standpoint in terms of intellectual property and who owns what that got that They did, they cut through that much more quickly than it usually. It usually happens if a person gets a covid vaccine now for example, will they need to get re vaccinated for the next flu season? So we talked about this a little bit before. I think it's unlikely um uh this um in 2021, although it might happen that way. And I think you could, you know, we maybe, I hope we don't have to do this, but we may be um in the business of trying to predict what variants are going to emerge each year and then use the annual flu vaccine campaign as a way to get people vaccinated with uh, subsequent strains, subsequent variants of the Covid virus. I don't think we really know if we're going to have to do that yet and I hope we don't, but it's a possibility. And it's something that gets talked about. Does a person need to get a separate regular flu vaccine if they get a COVID-19 vaccine? Yes, they do. This has nothing to do with influenza or influenza B and you need to have immunity to those now. Very interestingly, since we seem to be ahead of the curve here, I can't believe it Very interestingly, flu is almost almost completely went away this year. There was almost no influenza activity. They're typically a couple of 100 pediatric deaths each year. There was one this year and that experience was also seen in the southern hemisphere last our summer, their winter. And I think that's a function of people wearing masks and social distancing. But I also think it's a function of people washing their hands a lot. You know, flu vaccine is much more fluid, much more transmissible through phone mites than like stuff on the surface is scratching your eyes. Then um In COVID-19 seems to be so. I would hope that in the future, one of the, one of the um one of the sort of memories of Covid will be that people wear masks when they're sick, when they're when they have upper respiratory infections. It could be influenza when they go out in public. Can the flu vaccine and Covid? Nobody knows. The answer is probably yes. But we have to wait and somebody needs to figure that out biologically whether there's any blocking and it would probably not include the the live Attenuated influenza vaccine, the one that you give internationally. I can imagine that you'd want to try and avoid that. But again, mostly because the immune system that you rev up with the Covid vaccine may kill off the live influenza virus. Their issues about co administration. I think we need you need to look at fairly, fairly carefully before making sort of just assumptions. Um right now that the recommendation is to have two weeks between vaccinations. If you're getting say a new tetanus shot or a new measles shot, just give it a little time between them. Um I think we just answered that one before And I think um can those vaccines still transmit to others if they get infected? If they are vaccine failure one in 10,000 and if they get infected uh yeah they can they can transmit to other people. But this is not like again like oral polio vaccine where people shed virus, you'd have to be a vaccine failure and then get reinfected in order to transmit to others. And the chances of one in 10,000 chance for you to get infected and to come into contact with someone who has been vaccinated who is also a vaccine failure And have this which is one in 10,000 chance and they have them be a um um and have a sufficiently high viral load to transmit. We're talking you know, you know one in one in one in a you know, more than a million. So the answer is yes theoretically. But you know, very very tiny numbers. What tests other than antibody test can tell me how effective the vaccine is. So let's talk about antibody tests. First, There are two types of antibody tests and there were more than two. But there are two major types of antibody tests. There are tests that measure antibodies a spike protein and their tests that measure antibody to the nuclear caps and protein. After someone's been vaccinated, all the spike protein antibody says is that there's been a take of the vaccine. If you get the nuclear capsule program. Nuclear capsule antibody test. You're looking for occult infection. Okay, so nuclear capsules means real infection. Spike antibody in the presence of vaccination means that you've been vaccinated. Okay. In the absence of vaccine, Spike antibody also means infection. There are better tests, There are more definitive tests. Uh We do a uh an essay for neutralizing antibody at UCSF is an experimental thing in research labs. Stanford does stuff that looks at Anti Ace two inhibitors, the the binding protein. Um but those are really, you know, they're they're not in general use current recommendations or do not get an antibody test to prove that you have gotten that you have had to take of your vaccine. If you're going to get one, get make sure it's a spike protein antibody. And I would encourage you to tune in on thursday to listen to a discussion about this and immunocompromised people, which is where it's going to come up most. Should we, if you get them back, you know when they get vaccinated, do you need to check and make sure that they um that they had to take, that they develop anti spike antibody and if they don't do they need to be re vaccinated. So we'll have to uh I'm looking forward to that discussion. My parents had no reaction either shot. Does this mean that it's less effective providing immunity? How can they tell again? Not everybody gets reactions to their first or second doses. And so you could and we have lots of people in a big cohort that we follow have been vaccinated who have spiked or spike antibody positive, who had reported no reactions. So it is this doesn't mean anything one way or the other except maybe they're lucky. Um and having no reaction does not mean That they have deficient immunity if they have a reaction. So the negative predictive value is almost nothing is almost zero positive predictive value. On the other hand, if they have a reaction, that's probably really means something, especially like a big swollen axillary node or something. Okay, you could differentiate, first of all, I wouldn't bother to and the recommendation is not to. But if you absolutely had to know, you could do a spike antibody and sort this out. But once you do that, there's no recommendation about what you do with that, that information, whether you re vaccinate or not.