Can I Hug Grandma Yet?

April 1, 2021
By Lisa Germain, DDS, MScD

“Behind every problem, there is a question trying to ask itself… Behind every question there is an answer trying to reveal itself. Behind every answer there is an action trying to take place. And behind every action there is a way of life trying to be born.”  -Michael Beckwith

Since COVID-19 vaccine distribution began in the U.S. on Dec. 14, 2020, more than 76 million doses of the Pfizer and Moderna vaccines have been administered, reaching 15.3% of the total U.S. population, according to federal data collected by the Centers for Disease Control and Prevention. The U.S. is currently administering over 1.8 million shots per day. In addition, on Saturday, February 27, the FDA issued emergency approval for the third Covid-19 vaccine.  Developed by Johnson and Johnson, this is the first one of the three that requires a single dose.  This vaccine was found to reduce cases of moderate to severe Covid infection by 72 % (in the US) in adults, ages 18 and older in the stage 3 clinical trials 28 days after a single shot (worldwide efficacy = 66.1%).  In addition, this particular vaccine does not have the onerous cold storage requirements as the Pfizer or the Moderna mRNA serums.  Johnson & Johnson has pledged to provide the United States with 100 million doses by the end of June. When combined with the 600 million doses from the two-shot vaccines made by Pfizer-BioNTech and Moderna slated to arrive by the end of July, there will be more than enough shots to cover any American adult who wants one.

As the US is working to vaccinate a high percentage of its population to stop the spread of the disease, it seems that this might not be the only measure necessary to end the pandemic once and for all.  Like most things, as each question gets answered, the answers lead to more questions.  For example, why have we had an inexplicable decline in cases globally over the past several months? Should we be concerned about the mutant strains?  Can we depend on herd immunity to make up for the people who do not choose to get vaccinated? How long does my immunity last? If I have an autoimmune disease, pregnant or nursing, or other underlying medical condition is the vaccine safe?  Did the reported cases of death from the vaccine really occur as a result of the inoculation?   Why should I get the Johnson and Johnson vaccine since it has a lower percentage of success?  When can I hug Grandma?

The inexplicable decline in cases over the past few months is …inexplicable.  The number of new reported cases began to decline before the vaccine became available so there is no correlation with inoculation and the flattening curve.  Yet, while it did plummet, it seems to have plateaued and certainly is not gone.  We could speculate that people actually started to wear their masks over their mouth and nose instead of as a chin guard or neck ornament.  Perhaps it is a seasonal virus, after all, due to a combination of environmental factors and things people do in response to them.  Many viruses are not designed to thrive in warmer, sunnier and humid areas and seem to stay more virulent in cold, dry conditions.  The reasons are purely speculative at this point, but I think we need to look at progress in the right direction for any reason as a win regardless.  The decline in cases gives us hope that the end to the pandemic is in sight. 

The fact that all viruses mutate is not a comforting thought in general, let alone one as deadly as SARS-Cov-2.  Most of the time the variants that occur go undetected, however every so often a mutation will occur that is more efficient at infecting people and making them sick.  In the case of this particular virus, there are several variants that seem to be more efficient at binding to human cells due to the mutation causing a slight change in the protein sequence.  Scientists now believe that this accounts for the several reported cases of patients getting ill more than once from the disease. While experts don’t expect the variants to completely evade the vaccine they say that the broad immune response that they create will offer some degree of protection particularly against severe disease.  In addition, the mRNA vaccines can easily be modified to target the new variants.  Moderna has already synthesized a booster for one of the new strains. The really good news is that a new clinical trial is not necessary and the company only needs to file an amendment to their original request for emergency use.

Herd immunity occurs when a large percentage of a community becomes immune to a disease making the spread of the disease unlikely to occur from person to person.  The end result is that the entire community becomes protected-not just those that have developed the antibodies through either vaccination or from a history of illness. Once the number of people who can get sick and develop immunity exceeds what is known as the threshold proportion, the disease will begin to decline.  The threshold proportion for each disease differs.  However, the more contagious the disease, the greater the proportion of the population needs to be immune to the disease to stop its spread.  Perhaps this explains the recent decline, however there is no clear-cut evidence available to make this correlation.  One thing is clear however.  The more people that get vaccinated, the more likely and the faster that herd immunity will occur. 

The concern that a comorbidity, health issue, pregnancy, or autoimmune condition is a reason to forgo inoculation needs to be evaluated on a patient-by-patient basis in consultation with the individual’s physician.  Most recommend getting the vaccine regardless because there is a greater risk to a person’s health if they contract the disease than concern about an adverse treatment reaction to the serum.  There have been several reported deaths from ITP (Idiopathic Thrombocytopenic Purpura) post vaccine, most notably Dr. Gregory Michael, an obstetrician from Miami Beach.  While these deaths are still under investigation for a cause and effect relationship with the vaccine, hematologists with expertise in treating immune thrombocytopenia have reported that they suspect that the vaccine did play a role.  Yet, they have also said that the cases were likely to be very rare because they are theoretically the result of an unknown predisposition in some people to react to the vaccine by developing an immune response that destroys their platelets. The disorder has also occurred, albeit rarely, in people who received other inoculations, particularly the measles-mumps-rubella vaccine.

So far the clinical trials have yielded 9-month follow-up test results that indicate that the subjects still have high antibody titers.  So, we know that the vaccine should last that long…at least.  As more time passes, the answer to this question  “how often will I need to get vaccinated”?  will become clear.  It is also advisable to get the vaccine even if you have had the disease and have developed some natural immunity.  The inoculation will increase the antibody titer and give better protection from contracting the disease in a severe form.

The reported efficacy of the Johnson and Johnson vaccine of 68-72% versus the Pfizer and Moderna vaccines’ report of 94-95 % have many people worried that it is an inferior product.  While “vaccine hesitancy” has been widely reported, these   numbers have created a potential for “brand hesitancy” as well. This is where the headlines in the news media can be not only be misleading, but misinterpreted.  The facts are that the only important thing to measure is whether the vaccine prevents serious illness.  The good news is that all three vaccinations have breathtaking results in that realm with the Johnson and Johnson serum being equally effective as the other two.  All of them work for nearly 100 percent of people in preventing severe disease from Covid-19. 

The trouble with this virus is how lethal it has proven to be.  15 times more Americans have died from the Sars CoV-2 virus than within an average flu season. So, if we are truly keeping our eye on the prize, turning Covid-19 into something more like a mild flu or common cold means victory over the pandemic.  The headline effectiveness of the Johnson and Johnson’s 68-72% efficacy describes the vaccine’s ability to prevent all infections from SARS-Cov-2.  But preventing all infections is not as important as it sounds from an epidemiologic standpoint.  Unfortunately, the world is not going to eliminate SARS-Cov-2 anytime soon.  However, the vaccinations will all effectively manage the severity of illness from it by reducing it down to a manageable common cold or flu.

Can you hug Grandma yet?  Yes and no.  If you both have been vaccinated, a quick hug is probably fine.  Chances are you will not infect each other.   We know that the spread of the virus is increased based on viral load, exposure time, and proximity to the infected person.  If both of you are vaccinated, chances of spreading the disease as an asymptomatic carrier is very small.  So, give her a hug and then put your mask back on and socially distance.  While we clearly see light at the end of the tunnel, we are not completely out of the woods yet.