Illinois Medicine

Vol 22 - Spring 2021

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When should physicians expect to be able to offer access to the vaccines to elderly patients, essential workers and people with comorbidities? What about the general under-65, healthy patient population? What about children and teens? Initial vaccine deployment went to healthcare staff, and patients and staff of long-term care centers, which meant some of the elderly are included. In late January or early February, vaccines started to become available for those 65 or older and, in some areas, those with conditions that put them at heightened risk have been included as well. Other essential workers, such as firefighters, police officers, corrections officers and those in sectors like education, grocery stores, public transit, manufacturing, agriculture and the U.S. Postal Service, also have been offered vaccinations in February. Children and teens will likely be later in 2021, except for those with conditions that put them at risk for complications from the infection. How many Americans will be able to get vaccinated based on our current supply of Pfizer and Moderna doses in the pipeline, and what other vaccines should we expect to hear results about in the next couple of months? We are hopeful that Pfizer and Moderna can continue to increase production to help meet the needs of the nation to vaccinate as many people as possible. There are currently two other vaccines in the near- term pipeline. Janssen, which is partnering with Johnson & Johnson, applied for Emergency Use Authorization on February 4 (and was approved in late February). AstraZeneca is still enrolling in its trial, and likely we will see some data later this spring. With all the talk about vaccine development, we haven't been hearing as much lately about therapeutics. What drugs are currently considered state of the art? Remdesivir is useful for inpatient treatment of COVID-19 infection. Data suggest that the patients who will benefit most are those who require supplemental oxygen but are not yet mechanically ventilated. Dexamethasone, a steroid, has been helpful in hospitalized patients who require oxygen. Overall, antibacterial treatment is not helpful in COVID-19, and when concomitant bacterial pneumonia has been ruled out, antibiotics should be discontinued. We also now have outpatient treatments available in the form of monoclonal antibodies, including bamlanivimab and Regeneron. These are infusions and injections for patients at risk for complications who do not have oxygen requirements (or increased requirements for those on chronic oxygen). This decreases the risk of hospitalization and complications for some patients. What about pregnancy-style home testing that can be done in five minutes for under $5, which would be a game changer? Rapid testing and home testing can be a valuable tool. But the public must be educated about these tests. A negative test today tells you that you are negative today. However, if you have recently been exposed to someone with infectious COVID-19, you may not have a positive test for several days. In addition, some of the rapid tests do have decreased sensitivity and you may have false negative results. But you can address this with more frequent surveillance asymptomatic testing. This has been an effective tool to help control transmission in many settings, including here at the UIC campus and the U. of I. campus in Urbana-Champaign. In addition, the Illinois Department of Public Health has utilized this testing in long-term care facilities to control the spread of infection. When do you think it will become fully safe to reopen schools, dine inside restaurants, drink at bars, go to movies, concerts or ballgames, and attend religious services? Broadly speaking, what needs to happen first for each of those? After the holiday surges, it will likely be safe to open schools in a step-wise fashion. Initially numbers in attendance will likely be limited to allow for social distancing. Restaurants and bars present a unique challenge because these are the highest-risk activities: They bring together individuals from multiple households to eat and drink, and you have to pull down your mask to partake. Other venues like movies and sports activities may be able to open, but without food and drink vendors and at decreased capacity to accommodate distancing. Religious organizations have adapted activities to allow for masking and distancing. At what point do you think we will be able to ditch our masks even in crowded, indoor spaces? Broadly speaking, what needs to happen to reach that point? We will need to have significant immunity from vaccination and past infection within the community. That is likely not until fall or next winter. It is very dependent on the vaccine acceptance of the population and whether the vaccine can prevent asymptomatic disease and transmission. This data will likely become available in the next three to four months. At what point do you think we will know how long the vaccines last, and whether and how often we will need a booster shot? The two messenger RNA vaccines available appear likely to provide longer-term immunity. However, the preliminary data from the clinical trials is only two to three months. As we are further from the trials, we will learn from those who participated and from those who have already received the vaccines within the last two months. Other studies are enrolling those receiving the vaccine to evaluate antibody levels over time, which will help us project how long this will be protective. There is also the concern that variations in the SARS-CoV-2 strain may require a new vaccine. There are data that suggest that available mRNA vaccines may not be as effective against the South African variant. Work already has begun on developing a booster vaccine for this variant. Should those who have had the COVID-19 infection still get the vaccine? This is recommended, because we do not know how long natural immunity persists, and there have been a small number of cases with reinfection after 90 days. Patients should wait until after 90 days to allow those without immunity to get vaccinated first to help control community transmission. Those who have had prior infection appear to be more likely to have some immune system "memory" and may have a more robust immune response after the first dose of vaccine. Those who have not had past infection have a more robust response after dose 2. What is the immune response? This is the reactivity to the vaccine. It is an expected response, and it can include muscle aches, fever, fatigue, and pain and swelling at the site of injection. The immune system is responding to the vaccine and developing the ability to fight the COVID-19 infection when presented with the live virus. Given that both mRNA vaccines approved to date have efficacy of over 95%, this is likely why we are seeing more immune response with this vaccine, comparable to other highly effective vaccines like the new shingles vaccine and the measles, mumps and rubella vaccine. COVID-19 FAQs What questions might even those in the medical profession continue to have about COVID-19? We spoke with Susan Bleasdale, MD, medical director of infection prevention and control at UI Health, who gave us the latest research and thinking about the current state of the pandemic and how it will develop in the coming months. Susan Bleasdale, MD medical director of infection prevention and control, UI Health

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