Virus vs. vaccine: Questions and answers with key Cheshire Medical staff

To help, The Sentinel hosted a Facebook Live question-and-answer session Friday with Dr. Aalok Khole, an infectious disease physician at Cheshire Medical Center, and his colleague Ryan Hornblower, the Keene hospital’s EMS and emergency-management coordinator.

For those who missed it, here’s a transcript of the discussion.

When and how can I get the COVID-19 vaccine?

Hornblower: “This is the biggest question is when can I get my vaccine. If some of you saw the governor’s press conference yesterday, he talked about the rollout for the Phase 1B, which will be available to any residents who are 65 or older; the ... medically vulnerable with ... two or more [significant medical] conditions; and also caregivers of those medically vulnerable ... Also, residents and staff of residential facilities for intellectual and developmental disabilities, corrections officers and staff working in correctional facilities, and then first responders and health care workers not already vaccinated. So, the information on the process is still pretty fluid, and Cheshire is working with our public health network, with our state government to make sure that all people that want to be vaccinated are vaccinated. People that fall in these categories will be able to start scheduling on [Jan. 22] through the vaccines.nh.gov website with vaccinations starting on [Jan. 26].”

Are you going to be notified beforehand that you can start signing up on vaccines.nh.gov? Or are you able to just go right on Friday and sign up?

Hornblower: “You can go to the website and start signing up ... When you go to that public site, which here in this area will is on Krif Road [in Keene] as part of our public health network, you will need to bring something to prove that you are 65 and older — driver’s license, etc. — when you go there for [them to] double check.”

When people go to register, can you tell us anything on how that process is going to go?

Hornblower: “I don’t know all of those details yet. It’s still pretty fluid as we are getting more information from the state, and hopefully we’ll have some more information today to give out to the community.”

What area vaccination sites are going to be open for people here in the Monadnock Region?

Hornblower: “It will be through the public health networks. There’s 13 public health networks in each region and ours is at Krif Road for the Monadnock area ... We are working closely with Monadnock Community Hospital as well to incorporate everybody who wants to get a vaccine vaccinated.”

If someone is a New Hampshire resident but has a primary care physician in Vermont or Massachusetts, can they get vaccinated in their doctor’s state? Or do they have to be vaccinated where they live?

Hornblower: “You have to go where you’re a resident of currently.”

For people who may not be computer savvy or might not have email, is there another option to sign up for a vaccine appointment?

Hornblower: “Through the press conference yesterday, the governor had stated people can call the 2-1-1 number to get assistance on how they would register if they are having troubles with Internet, being tech savvy.”

How are people who have two or more serious medical conditions going to be notified that they can register? Who should they be talking to about getting an appointment?

Hornblower: “We are working on the details about how to provide documentation now with the [N.H. Department of Health and Human Services and the Division of Public Health Services]. We will update [Cheshire Medical’s COVID-19 information] page when that information is available. Please do not contact your provider directly for this information at this time.”

*This statement was sent by a hospital spokeswoman to correct information provided during the Facebook Live event.

Next Friday will start Phase 1B of the vaccination phases, followed by several other phases throughout the next few months. Do you anticipate the way people register to get vaccinated changing along this time frame?

Hornblower: “I’m sure with anything as we are moving forward and learning the process that things will evolve and improve or they may find better ways to reach everybody, so I would say it’ll probably remain pretty fluid as we move through the phases.”

Will the vaccine administration be done in a drive-thru style, like it has been with COVID-19 testing?

Hornblower: “It’s a drive-thru site right now ... that is something that I’d have to defer to the public health network as we move forward as they are coordinating many aspects of that working with the N.H. National Guard.”

What does the vaccine actually do for you?

Khole: “Both of these vaccines that have currently been approved in the U.S. — the Pfizer and the Moderna — both are mRNA vaccines and work in a very similar fashion. The technology is not entirely new; this is something we’ve worked on for more than a decade. It’s just that they’ve tried to use this with other vaccines, such as influenza and Zika [virus], but those vaccines for whatever reason didn’t show as robust a response as we saw with COVID-19. That is one of the reasons that we had this technology ready, so we could go live sooner rather than later. So at no point have we compromised in any way in the production of these vaccines or utilizing this product ... How does it benefit the person receiving the vaccine? When you look at the data ... they saw that both these vaccines had efficacy anywhere between 94 and 95 percent in preventing symptomatic COVID-19 disease ... What we know about COVID-19 is a significant portion of this illness, almost 35 to 40 percent depending on the data you see, talks about asymptomatic infection and can you prevent asymptomatic infection as well? That hasn’t really been studied in any of these trials, but what’s important to understand is it’s very difficult to believe that a vaccine that prevents symptomatic illness will not prevent asymptomatic illness ... However, until that part is known in a confirmatory fashion ... that is one of the reasons we are saying that even if you get the vaccine and even if you’re immune, conservational measures do not change, be it universal masking, be it physical distancing, be it ... washing of hands, avoiding gatherings, that all is not going to change, at least at this time with whatever we know ... and both of these vaccines definitely reduced the severity of illness.”

How long will the vaccine last?

Khole: “We don’t really know that for sure ... Coronaviruses, historically, have gone through mutations significant enough to affect someone’s immunity — that usually happens every two or three years — so is that what we’re going to expect? We really don’t know ... We at least hope it will be there for six months to a year, but both of these [vaccine] companies are actively looking at that.”

What happens if you don’t get the second dose of the vaccine or if you get the second dose after the recommended time frame?

Khole: “So the first part of that question ... what happens if you don’t get the second dose — and that can happen, right? If you have an anaphylactic reaction to the first dose or, for whatever reason, someone decides to skip the second dose. We really don’t know what sort of an immune response they are going to mount. When the data looked at certain individuals ... between dose one and dose two, the vaccine efficacy was somewhere between 50 and 55 percent. So it did offer some immunity, but again, the first dose is a priming dose, and the second dose is a booster dose. So what happens to someone who doesn’t get the second dose? ... We don’t really know. And that is why the studies were done with two doses, and that is what’s recommended.

For the second part of your question, what if someone gets it beyond the time interval? The way the [Centers for Disease Control and Prevention] is recommending it right now is at least 21 days between the two Pfizer doses and at least 28 days between the two Moderna doses. There is a four-day grace period allowed for each of these products, which is to be used as an exception, not as a norm. So you want to try and stick with the interval as much as possible, but there is no reason to believe that a slight bit of an extension beyond these regimens — so say someone gets it on day 25 for Pfizer or day 32 for Moderna — there is no real data to say that’s not allowed and you’ll ... have to repeat the series. That is not recommended because the hope is you’ll have enough of a priming response with the first dose that a slight bit of an extension or leeway with the second dose is allowed and you should still develop a similar response as you would otherwise.”

How do you schedule the second dose?

Hornblower: “There’s some more information that needs to come out with that. Currently, with the [phase] 1A people in the public sites, once you’ve had your first dose, you are then eligible to sign up for your second dose once they know what vaccine you have and how far out you need to schedule that, depending on when they have clinics.”

What is in the vaccine?

Khole: “Primarily, both are mRNA vaccines, so the main product is mRNA. Again, it’s not the exact same product, they are both patented differently, but in general the compound is the same. What’s important to understand is mRNA in itself is ... unstable when it is exposed to heat. So when they had to manufacture these vaccines, they had to coat the mRNA in a lipid molecule. That lipid molecule is made out of polyethylene glycol ... and that has most of the reactions that we are seeing. And again, these are not over and above what you’d see with some other vaccines ... If you look at the individual components, both of them have salts, so Pfizer has sodium and potassium salts, and the Moderna vaccine has something called tromethamine, and if you go on further, both of them have cholesterol and certain other ingredients as well.”

What are the adverse reactions I could experience after getting vaccinated?

Khole: “Both these vaccines are labeled as what is known as reactogenic. So a comparison, if I had to make one, would be with the shingles vaccine, and [anyone] who hasn’t experienced that vaccine, I’d ... think of the tetanus vaccine you’d get. There are two components. One is a local injection site reaction, which would include pain, swelling, redness and some warmth, which lasts no longer than 24 to 48 hours. I think most of what our experience has been, and even personally, it lasted for probably 12 to 16 [hours] at the most. The second set of side effects you would look at is systematic, so the [most common] ones we’ve seen ... would include chills, fatigue, headache, myalgia (so muscle aches) and some complained of joint aches. Fever was seen in about, at least with the Pfizer product, in about 4 to 5 percent of the individuals after dose one and about 15 to 17 percent after dose two. Again, nothing that is not expected.

This clearly shows that your immune system is functioning. The effects are higher after dose two because that’s a booster phenomenon. The first one was a priming phenomenon. And interestingly, when you look at the data, the older individuals who had received the vaccine had lesser side effects compared to the younger population, so that is something to keep in mind as well. A common question I’m asked is, ‘If I don’t get any side effects, does that mean my immune system didn’t work and the vaccine’s a waste?’ I would say no. Each individual reacts differently, and that is why we have percentages. It’s not like 100 percent complained of side effects, and everyone’s tolerance is different. But none of these symptoms should last more than 24 to 48 hours because if they do, as I said before, [the vaccines] are not 100 percent, so there is a chance that you’ve acquired COVID either before or in between your two doses of the vaccine ... For example, the vaccine will not give you COVID-19, so the vaccine should not give you a cough, should not give you shortness of breath, should not give you nausea, vomiting or diarrhea. So if you have these symptoms, then you might as well get tested. If you have headaches, chills, myalgia, wait it out. It is OK to take Tylenol ... or any other anti-inflammatory drug.”

Are there any ingredients in the vaccine that people could be allergic to?

Khole: “Polyethylene glycol is what’s thought to be potentially driving some of the severe reactions that we are seeing, but interestingly, when you look at the data we use, polyethylene glycol is used in several other drugs and food products ... The CDC published [in their Weekly Morbidity and Mortality Report] last week that even with the vaccines, when they actively tracked data from all over the country, the rates of anaphylaxis ... has been about 1 in 100,000 people.”

Some have said the vaccine can cause infertility. Is there any merit to that?

Khole: “None of the data or clinical trials show that. Interestingly, if you look at the Pfizer trials, there were actually woman who ... found they were pregnant in between dose one and dose two and even after dose two ... There is really no proven evidence to show that this effects either male or female fertility, per se. I think that it’s one of those things that comes along when a vaccine is launched that there will be certain rumors, but this is myth at this point.”

Can someone who is pregnant or breastfeeding get the vaccine?

Khole: “Both these populations were really not included in the actual trials ... but what’s interesting to note is, again, it’s not a live vaccine, so it should not have counter implications or have adverse effects on the child — either one which is not born yet or one even post-birth through breastfeeding.”

One reader asked with the long-term side effects of the vaccine still unknown and the chances of dying from COVID-19 less than half of 1 percent, are we better off getting the vaccine or not?

Khole: “You can look at it from at least two points ... We really don’t have hardcore evidence saying that the long-term side effects are such that we’ve gone and pulled these vaccines out of market. So I think even though in the current time we don’t know the long-term side effects associated with this vaccine ... it would be hard for me to believe that would happen with this particular product. And I’ve heard a lot of people say this, ‘The mortality rates aren’t that bad, especially in certain age groups, so why should I really worry?’ What I would like to highlight is a very common thing we are now seeing with COVID is these long-term complications after having COVID-19 ... even months or potentially ... a year out from when they were first diagnosed. So even though we know, OK, the mortality rates may not be that high as you may see with something else ... I think it’s easy to understand the vaccine is probably better.”

How do we know, with the vaccine being developed so quickly, that it’s safe? What was shortened or skimped on that isn’t usually?

Khole: “Right off the bat, they have not compromised on any of the safeguards, so we are not worried about the safety of this vaccine. I think it is completely safe and those that are interested should get it. I think one of the reasons why we saw this coming into the market so fast is the technology, as I said before, wasn’t entirely new. These are the first mRNA vaccines to get approved, but mRNA ... has been experimented with for more than a decade now ... The other thing that they did was these were one of the first vaccine approaches where production and trials moved simultaneously. What’s the risk we ran with that approach? If the trials failed, you lost a lot of money producing a vaccine which really wasn’t effective, but the advantages paid off for us. In November they came out with data saying that these vaccines are beneficial, and you’d already built a repository of enough product that within 24 hours of approval, they could start shipping these out to the state. I think from a vaccine regulatory perspective, they went through all the appropriate steps.”

One reader asked if a school district has teachers and staff vaccinated, should the district evaluate their hybrid learning model and move back to on-site learning?

Khole: “That’s a fair question ... It’s really commendable the job that school districts, and for our local site Keene State College, the job that they have done is amazing. Everyone was worried with everyone moving toward in-person learning that oh my God, we’re going to have outbreaks and we’re going to have a tough time controlling this, but if you look at the numbers, they really didn’t contribute much to the case numbers or outbreaks. I think whatever schools and colleges did — be it testing, be it guidelines, be it conservative interventions within their setting — worked, and I think that’s something to take into consideration as well. As long as we keep doing that, plus now you add the tool of once the staff is immunized ... can they move back? I think that’s a fair choice.”

This article has been updated to correct a statistic.