On the road to normal life

How building a cocoon may beat joining a herd

I have to admit, over the holidays I felt a slump. The world is not the same as it was in 2018. It’s been far too long since I have seen or hugged my parents and the constant bad news and uncertainty has been weighing on me.

Still nearly half Americans aren’t sure they want the coronavirus vaccination. With these numbers it will be a long time until we reach herd immunity, and we will likely do so at the cost of many more deaths due from rapidly spreading COVID-19 and it’s variants. Herd immunity seems for now a far-off goal.

Fear and hesitancy are understandable given the missteps we have taken along the road. “It’s just staying home for two weeks”, “don’t wear a mask” and “it’s not airborne” were perhaps the wrong public health messages at the time and many have lost trust.

But today I want to do my part in expressing my confidence and excitement for the vaccine. It’s a new year and we have reasons for hope! We have data from millions of people who have taken the Moderna and Pfizer vaccines, the vaccines seem to work well and the side effect profiles are in the range of what we see from other vaccines.

What do I mean by this? The vaccines seem to prevent about 95% of severe infections from COVID-19 and after the first dose of moderna the risk of being an asymptomatic carrier of COVID-19 decreases by nearly 60%. While we are advising to continue masking and distancing precautions post-vaccine until community spread is lower and vaccine uptake higher, we anticipate that vaccinated individuals will have a lower chance of spreading COVID-19. The goal of vaccination is to get us back to normal life and allow us to take off our masks and hug our friends again.

The vaccine side effects are mostly what you’d expect fatigue, fever, headache and soreness. We’ve followed the news closely about anaphylaxis which appears to be more common than with the flu vaccine though still rare (1 case per 100,000 vaccines) and treatable. Other immune reactions such as Bell’s Palsy remain under scrutiny, but almost certainly you are more likely to get these reactions should you get COVID-19. The overall risk of the vaccine is less than the risk of the illness.

But the vaccine can only “save the day” if individuals choose to get it and the truth is even when we near herd immunity, we will continue to have pockets of less protected individuals (ie. unvaccinated or not immune through illness) having outbreaks. Even herd immunity not a magical off switch. So how can we protect the most vulnerable in our community and our loved ones?

Cocooning is a term pediatricians use all the time. The concept references protecting vulnerable individuals by surrounding them with vaccinated individuals. For example, when caregivers and family members have pertussis and flu vaccinations up to date, a newborn has a lower chance of getting sick because vaccinated individuals are less likely to be infected or transmit the illness.

While we mostly think of cocooning as a way of protecting infants, cocooning is a strategy that can protect the elderly or the medically complex. If all the high risk individuals or people surrounding someone high risk are vaccinated, we’ll have the most substantial impact on decreasing deaths and hospitalizations from coronavirus. Since 80% of deaths and only 15% of cases represent individuals over 65, protecting this populations seems particularly important. 

Yet in many nursing homes, few staff have elected to receive the shot. This is a problem. If all the elderly and high risk are fully vaccinated, five percent (or more if they are less immunocompetent due to underlying/complicating conditions) may still contract COVID-19. The best way to eliminate that risk is by cocooning and achieving high levels of vaccine uptake within those facilities AND those who visit and service them. Our individual choices matter most in terms of protecting our local community from the risks of spreading virus.

Cocooning will also be a great strategy to protect children from infection while we await vaccines. Hopefully by summer we’ll be vaccinating some children, but in the meantime vaccinating the adults in a community will decrease transmission and reduce the number of infected children. Particularly newborns and children at higher risk (such as those with sickle cell disease, trisomy 21, type 2 diabetes, congenital heart disease, prematurity or severe obesity) may benefit from being intentionally surrounded by vaccinated adults. 

If you’ve followed me on instagram, you may have seen that I have this thing about being a cart returner at the grocery store. This analogy plays well with vaccine uptake. At grocery stores near me, large percentages of people don’t return carts. The consequence is that the parking lots are worse for everyone. Fewer spaces available, your car may be dinged, and visibility is worse which may make accidents more likely.

However, everyone can’t return their cart. Some have disabilities or many small children and find it infeasible. It just so happens that those who may have the most difficulty may also be the most adversely affected by the cart-hazard situation by having a cart block a closer parking spot or a child dart out unexpectedly in an area with poor visibility. Those of us who can return our carts should not just for our own benefit, but for everyone’s benefit.

Our pandemic lives aren’t great. We see less of our loved ones, children are getting inadequate access to school, restaurants are going out of business, and mental health problems are through the roof. But we have agency and each of us will have an opportunity to do something to help. To take the vaccine despite the small risk, the uncertainty and the inconvenience, and to make things better for ourselves, for our loved ones and for our broader communities. We can be a part of the solution.

I feel like my science-interested subscribers may not need this convincing, but somehow hope that putting this information out into the world will help address some of the hesitancy. So please share with anyone who might find it helpful.

For more general information about the COVID-19 vaccine, I’ve loved content from my former colleague Dr. Risa Hoshina and Dr. Jesse O’Shea who created the instagram #HCW4science.

I’ve addressed a lot of questions about breastfeeding in this instagram post and this article from Vogue.

I’d encourage pregnant women to look for resources from American College of Obstetrics and Gynecology. 

I will be back in a few weeks to talk about something not COVID related, perhaps some information about discipline.