You've been vaccinated. Now what?

What to do when you've been waiting so long to do something.

"A single courageous State may, if its citizens choose, serve as a laboratory; and try novel social and economic experiments without risk to the rest of the country." —Justice Louis Brandeis, New State Ice Co v Liebmann, 1932

Based on Justice Brandeis’s quote from his decision in 1932, the states have been called “the laboratories of democracy”. Now, they could also be called the “the laboratories of virology.” However, these experiments DO pose risks to the rest of the country. There is no impediment to traveling between states, so what happens in one state, can spread to another.

Recently, Gov. Abbott of Texas has decided to remove all restrictions associated with COVID-19 disease. He has decided that the citizens of Texas can rely on their own judgement, as well as the deployment of vaccines, to determine what steps they should take, if any, to limit spread of the SARS-CoV-2, the virus that causes COVID-19 disease. While some units of government—counties, cities—may choose to enact their own restrictions, the Attorney General of Texas has vowed to strike them down.

This won’t go well. Paging Dr Wayne Wenowdis.

The B.1.1.7 variant, first described in the UK, is spreading across the United States. This is but one of the “variants of concern” (VOCs—not to be confused with volatile organic compounds, also abbreviated VOCs). As it does, there is growing evidence that it may be more transmissible among children than the preexisting strain of SARS-CoV-2. This has been seen with the youth sports outbreak in Carver County, Minnesota and formed one hypothesis for the rapid spread in the UK when adults were locked down, but schools were open.

Additional VOCs identified in South Africa (B.1.351) and Brazil (P.1) have also been identified in the United States, although they have not spread as quickly as B.1.1.7.

What does that mean for those of us who have received the vaccine. Are we protected from these variants? If so, how well?

Initial studies of vaccines approved under Emergency Use Authorization in the United States—Pfizer/BioNTech, Moderna and Johnson & Johnson/Janssen—all show effectiveness against both the historically dominant strain, as well as the VOCs. It is important to remember that effectiveness in the vaccine trials refers to risk of illness, not necessarily risk of transmitting virus to other people. Studies in the laboratory (called “in vitro” [in the glass]) of the Pfizer/BioNTech vaccine do show some effectiveness against these VOCs. Of course what happens in vitro doesn’t always equate to what happens in vivo (in living tissue)—just ask any pharmaceutical scientist. It will take some time to understand how well vaccines really protect against VOCs.

In the meantime, our friends at the Centers for Disease Control and Prevention (CDC) have published some recommendations about what vaccinated individuals can do, starting two weeks after they have completed their vaccine series. Two weeks after completing the vaccine series is considered the time when the vaccine has reached full effect, i.e. “fully vaccinated”.

To start, you can hang out indoors unmasked with other fully immunized people. This could also include sharing a meal—so that’s a big deal! It’s also easy to understand, unlike all the other recommendations, which are subject to caveats and nuance.

These caveats include:

  • meeting unmasked with other non-vaccinated people, unless some of them are high-risk or live with high risk people. The basis of this caveat is that we still don’t know how much, if any, fully-immunized people can transmit disease.

  • Not quarantining if you are exposed to someone with COVID-19—unless you develop symptoms (vaccine “only” 95% effective—we have seen some people who get sick after completing vaccination), or you live in a group setting.

That’s it—for now!

So as of the time of this post, even if fully immunized, we should continue to mask and social distance with the general population. If traveling, it would be best to continue to mask. And, if traveling—which, after all, is how all these VOCs from Brazil, UK, South Africa and elsewhere get introduced into the USA in the first place—we should continue to quarantine for 7 days after return. As the multiple superspreader events at the White House last year demonstrated, relying on testing only (rather than including masking and social distancing) to prevent transmission will eventually fail. Even if testing negative prior to travel, testing 5 to 7 days after return is helpful to assure that you did not pick up a vaccine resistant variant. Even better, would be to avoid traveling, at least until we understand how well vaccination-induced immunity stands up to these VOCs.

When will we know more about what else we can do? Hard to say, but based on past experience, it typically takes 6 to 8 weeks to see if an intervention has epidemiological effect against COVID-19. This has been true with social distancing, masking and likely will be the case with vaccines. My guess is that by late April we will have a good sense as to whether these vaccines will truly reduce transmission of the VOCs.

Let’s minimize the coming spring surge as much as possible, save lives, and get through this!