You Have Been Vaccinated. What Now?

Can you throw away your mask and go back to pre-pandemic activities? No.

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Caution is still the byword, and you will need to be cautious for many months to come both to protect yourself and to help quell the pandemic.

You may be wondering if you can go to a restaurant, hug your grand-kid, feel safe in the supermarket, go to a movie, and in general, just go back to normal living after a year of the pandemic upheavals. These are important questions about daily living. Here are some of the facts to help you make informed decisions.

There are two vaccines authorized in the US by the Food and Drug Administration for emergency use that are highly effective, one from Pfizer-BioNTech and one from Moderna. Once a vaccinated person is a week or two after the second dose and exposed to the virus, there is a negligible chance of dying or of developing a severe infection. That is the good news and it really is good news.

In the large 43,000 (Pfizer) and 30,000 (Moderna) volunteer Phase 3 trials, there were no deaths and only one severe infection among those who received the vaccine compared to those in the non-vaccinated groups.

Specifically, in the Pfizer trial as reviewed by the Food and Drug Administration, and also reported in the New England Journal of Medicine, there was one (vaccinated) vs. 9 (unvaccinated) people with severe infections. In the Moderna trial, there were no severe disease cases among those vaccinated compared to 30 in the non-vaccinated group in which there was one death. This is an excellent outcome especially considering that both trials enrolled many volunteers with a high risk of developing severe disease due to age or underlying disease.

There was a slight risk of developing mild to moderate infection. The Pfizer vaccine was 95% effective (8 vaccinated vs. 162 placebo volunteers), and the Moderna vaccine was 94% effective (11 vs. 185) in preventing these infections beginning one to two weeks after the second dose. Once again, an excellent outcome.

These graphics on the Pfizer trial (top) and the Moderna trial (lower) from the FDA website (or the New England Journal of Medicine) are telling.

Pfizer — BioNTech Data from FDA. Cumulative cases among Placebo in Red and Vaccinated in Blue.
Moderna Data from FDA. Cumulative cases among Placebo in Blue and Vaccinated in Red

But here is an important consideration. As of now, it is not known whether those who did develop mild to moderate disease were also contagious, i.e., capable of transmitting the virus with breathing, speaking, singing, coughing, or sneezing. Being contagious would be expected among non-vaccinated people who develop an infection, but what effect does the vaccine create? Additionally, were these vaccinated individuals contagious for a few days before symptoms appeared, as would be expected in non-vaccinated individuals? For now, there are no clear answers.
Another question is whether some portion of the vaccinated individuals had an unknown asymptomatic infection and if so, were they contagious as would be expected among those not vaccinated? Infectious disease experts have differing opinions but, at least one investigation of a large pool of vaccinated individuals indicates that transmission is likely but with less intensity and for fewer days than in non-vaccinated persons. But for now, wait and see what new information tells us.

No one knows yet how long immunity will persist after vaccination. Months? Years? Early results indicate immunity lasts at least six months. As more people are vaccinated for longer time periods, this may lengthen. If immunity does decline over time, will a booster dose be effective to reclaim protection.?

Three other vaccines are in line for possible emergency use authorization.

Johnson and Johnson’s vaccine data has been submitted to the FDA; approval may come as soon as the end of February. The FDA data analysis made available February 24, 2021, indicates that the vaccine was 67% (116 vaccinated individuals vs 348 cases placebo group) effective in preventing moderate/severe disease beginning 14 days after vaccination and 66% (66 vs. 193 cases) after 28 days. The image below shows this graphically. There were no Covid-19 related deaths among the vaccinated group and seven among the placebo group.

Johnson and Johnson Data from FDA. Cumulative cases among Placebo in Red and Vaccinated in Blue

The Oxford — Astra Zeneca vaccine has already been approved in the United Kingdom, the European Union, and the World Health Organization. The company will apply to the FDA once a large trial ongoing in the United States is complete.

Finally, the Novavax vaccine is slightly behind the others time-wise, but data should be available within a few months. Early reports are that they each prevent severe disease and deaths. Information regarding contagiousness and asymptomatic infection will be forthcoming but later.

Why did the Pfizer and Moderna clinical trials not include testing for contagion and asymptomatic infection? The short answer is that the critical need was to rapidly determine if the vaccines would prevent overt disease, especially severe cases, and deaths. If so, they were eligible for emergency use authorization. The concept was for other issues to be addressed once the key ones were established. The companies are now addressing these concerns.

Until the answers to these questions are known, probably within a few months, it is essential to continue to follow the same COVID-19 precautions recommended by the Centers for Disease Control of mask-wearing, social distancing, avoiding crowded settings, avoiding areas with minimal air circulation, and maintaining good hand hygiene.

The virus is still out there, circulating, causing disease and death. Each vaccinated person needs to protect yourself with these steps and concurrently protect others should you have an asymptomatic infection and be unknowingly contagious.

There is another reason to follow precautions, solidarity with those still unvaccinated. Not everyone has been vaccinated yet and the virus is still circulating at high levels. Vaccinated individuals need to show solidarity with others who have not yet been vaccinated.

Finally, some mutants are circulating that are of concern. Most seem to be well controlled by the current vaccines but one from South Africa has led to some angst. A small trial of the Oxford-Astra Zeneca vaccine showed it was less able to prevent mild to moderate disease, but the developers at Oxford believe it will still prevent severe disease and death. Nevertheless, the occurrence of new variants that might evade the vaccines presents one more reason to be cautious.

The key for the future is to slow and eventually stop the transmission of the virus. That will take steadfast persistence in both using precautions and getting the populace vaccinated.

In summary, despite being vaccinated, everyone should continue to follow the basics of protecting yourself and others from the virus. Vaccines alone, although excellent and essential, cannot be expected to resolve the pandemic single-handedly.

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