Dr. Ramers: It’s OK to be skeptical, and it has been very confusing as small bits of information come out at different times, but the way science works is that individual studies come out one by one and eventually yield an evidence base and a consensus that we take to be truth and fact until disproven.  The science behind vaccines of course will continue to evolve, but to date these COVID vaccines have been the most intensely studies in history and we have a very good understanding of the rare safety events (most are on the order of a few per million which is about the chance of being hit by lightning).  All the epidemiologic data as well as our collective experience as healthcare workers has shown us that the overwhelming majority of severe cases of COVID-19 requiring hospitalization and death have occurred in unvaccinated people, demonstrating that the vaccines are the best tool we have at protecting people and decreasing the chances of suffering these consequences.  

Regarding masks, I have largely the same answer.  Studies done in labs that simulate droplet transmission are absolutely clear that they can prevent droplet spread from one person to another.  The epidemiology strongly supports this as well with many studies showing that universal masking in schools reduces spread by around 30-40%.  Not perfect, but a very good tool.  Finally, it’s important to realize that correct mask-wearing technique (cover that nose!!) and the quality of the mask explains a lot of the variation and why masks don’t work even better.  N95 masks are better than KN90 masks which are better than surgical masks, which are better than cloth masks, which are better than bandanas and gaters.  I take care of around 50 highly infectious COVID patients per week in our monoclonal antibody clinic and have not yet contracted COVID (I have the blood tests and weekly negative PCRs to prove it!).  Being fully vaccinated and wearing an N95 properly and consistently has protected me and potentially saved my life.  

Dr. Bradley: As we shared, reported cases are actually not all confirmed.  When the information on the CDC’s investigation into whether the reported cases were actually supported by reviewing the children’s medical documents and speaking to their doctors, only half the reported cases appeared to be truly related.  While any rate in these children is certainly of concern, the true rate is probably closer to 1 in 15,000.  Most important is that all the children with myocarditis recovered and there has not been a single case of long term injury, and no deaths.  The CDC and FDA are continuing to track side effects, and when the number of kids who have received vaccine is in the millions, most all of the side effects will be known and will be shared with us all.

...Students and staff were sick with Covid. Students spread this to their vaccinated parents that then also became very sick. This vaccine does not stop someone from contracting Covid or stop them from spreading it. The CDC also stated that the viral load of an unvaccinated case and a vaccinated “breakthrough” case are the same. I personally know of 14 people in my life that were fully vaccinated but still contracted Covid and some also spread it to others within the past few months. So to force children to take this brand new vaccine does not make any scientific sense. 

Dr. Bradley: Breakthrough infections in vaccinated people were discussed, and no amount of immunity from either vaccine or from natural infection will reliably protect someone from a close exposure to an infected person.  Adults are better able to keep apart from other adults with ‘colds’ or ‘coughs’ but it is difficult for a parent or grandparent to not hug a symptomatic child with COVID.  Kids are not reliably able to keep apart from their friends when not under adult supervision, which is probably why it is currently spreading in schools.  The contagiousness of vaccinated people with COVID is less than the contagiousness of those with COVID who have not received the vaccine.  With fewer symptoms, it is likely that vaccinatated people have less cough than unvaccinated, and the amount of virus in your mucus drops much more quickly if you were previously immunized, than if you were unvaccinated.

Dr Bradley: Doctors not only allowed, but are supposed to discuss vaccine safety with all parents.  That is their job.

Dr. Bradley: Antibody levels decrease over time, but that happens with all vaccines.  The body switches to a “memory” mode of immunity, where the cells that produce antibody go into hibernation until the body is exposed to COVID again.  Dropping antibody in the vaccinated does not mean that you will get the same severity of disease as the unvaccinated.  The less we can vaccinate, and the more people get COVID disease, the more likely that a new mutant will develop, one that is more deadly than the current strain, so decreasing the number of infections everywhere in the world is a high priority.  This virus does not mutate nearly as fast as influenza, and actually has an internal mechanism to stop mutations within its RNA, that works reasonably well.  We discussed the benefits of vaccine, even one with Emergency Authorization, against the risks of the infection.  So far, there are no significant long term side effects that occur with any substantial frequency in the vaccine, which now has been tracked for safety for over a year, and is continuing to be tracked by FDA and CDC.  The virus is far more dangerous to children than a spike protein vaccine.

Dr. Bradley: Covered in discussion.  We also now know, as of November 2, from data collected and reported by the CDC that in certain regions of the United States, up to 35% of children have evidence of infection by blood test, without our even knowing and far fewer cases actually having been reported, so the ‘pandemic’ is still ongoing in the unvaccinated (both children and adults).

Dr. Ramers: There seems to be a ‘false confidence’ in natural immunity.  As I mentioned, I see patients every day who have infections precisely because their natural immunity has failed.  It is true that some people do gain good protection after an infection, but there are reasons to be skeptical that natural immunity will protect everyone.  Some viruses do mutate rapidly enough to be able to evade even a very good immune response. Some infections are able to evade the immune response from the beginning (examples include HIV, Hepatitis B, herpesviruses HSV-1/HSV-2, varicella/chickepox, HPV).  In other examples, even a good ‘natural immunity’ response isn’t enough to prevent from reinfection.  If we take other coronaviruses as an example (such as one of the less lethal ‘common cold’ ones like Coronavirus HKU1 or OC43), people can get reinfected by the same virus every single year because immunity tends to fade away.  While it is true that surviving an infection should give some protection, the data suggests that this protection is highly variable from person to person.  And finally, we really don’t have very good tests to differentiate who is truly protected and who isn’t.  While we can easily send a spike Antibody test, these tests don’t give an adequate picture of the full immune response, and don’t even tell us how good that person’s spike protein antibody actually is. There are much more sophisticated tests (neutralizing antibodies, tests for memory B-cells, memory T-cells, etc) that are only available in research studies.  So not only can we not guarantee that natural immunity will be strong enough or last long enough to protect someone, we don’t even have a reliable way to test for it.   Natural immunity PLUS vaccination actually gives the best responses we have seen, and result in something called ‘hybrid immunity’. The uncertainty and variability that has been observed with natural immunity, combined with the very high levels of protection seen in COVID survivors after vaccination are what’s behind the recommendation that all should receive vaccination, including those who have survived COVID. 

Dr. Ramers: This is not necessarily true and gets to a ‘false confidence’ in natural immunity.  As I mentioned, I see patients every day who have infections precisely because their natural immunity has failed.  Some viruses do mutate rapidly enough to be able to evade even a very good immune response. Some infections are able to evade the immune response from the beginning (examples include HIV, Hepatitis B, herpesviruses HSV-1/HSV-2, varicella/chickepox, HPV).  In other examples, even a good ‘natural immunity’ response isn’t enough to prevent from reinfection.  If we take other coronaviruses as en example (such as one of the less lethal ‘common cold’ ones like Coronavirus HKU1 or OC43), people can get reinfected by the same virus every single year because immunity tends to fade away.  While it is true that surviving an infection should give some protection, the data suggests that this protection is highly variable from person to person.  Natural immunity PLUS vaccination actually gives the best responses we have seen, and result in something called ‘hybrid immunity’. The uncertainty and variability that has been observed with natural immunity, combined with the very high levels of protection seen in COVID survivors after vaccination are what’s behind the recommendation that all should receive vaccination, including those who have survived COVID. 

Dr. Ramers: This is an area of active research right now.  The fact is that we can’t guess how long immunity will last until we’ve had enough time to follow up large groups of people to see how likely they are to be reinfected.  There is pretty good evidence that vaccinated people will maintain really good ‘immune memory’ in their long-lasting memory B-cells and memory T-cells, even if their antibody levels wane over time. This means that even if full protection from infection fades away over time, the body will still be likely to maintain a really good and rapid response if/when exposed again.  This is why even though breakthrough cases are happening, we’re seeing that the vast majority of them are mild and don’t make people very sick. It’s still the unvaccinated that are making up the overwhelming majority of serious cases that are landing people in the hospital. 

Dr. Ramers: Complicated question, and it depends on what we’re trying to prevent.  Are we trying to stop all infections, or is the goal to prevent serious infections, hospitalizations or deaths.  The primary series (2 shots Moderna or Pfizer) are still doing quite well at preventing most people from having severe cases and winding up in the hospital.  However, it has become clear that more vulnerable people with weaker immune systems are having their protection wane a bit faster.  That’s why the current recommendation for boosters is strongest for those who are severely immunosuppressed, those over age 65, and those over age 50 with underlying medical conditions.  The company of course wants to sell more of its vaccine, so they are asking FDA to approve boosters for everyone. FDA and CDC will not allow this unless the evidence is starting to show that everyone would benefit from a booster and that the safety is acceptable.  

Dr. Bradley: The best, most comprehensive and current information on COVID disease was presented at the CDC meeting to academic advisors (people like Drs. Ramers and Bradley), available at the CDC website: https://www.cdc.gov/vaccines/acip/meetings/downloads/slides-2021-11-2-3/03-COVID-Jefferson-508.pdf

In general the lower the antibody level, the more a person is likely to have symptomatic disease on re-infection, and immunization is known to greatly reduce serious disease, hospitalization, and death in adults.  However, antibody is only part of the body’s defense, as specific lymphocytes (specialized white blood cells) can also recognize COVID virus and protect from infection.

Dr. Bradley: More effective at preventing spread of COVID than masks, but since masks are not injections, masks would be considered safer.

Dr. Bradley: Covered in discussion: 3000 children with vaccine, and 1500 got saltwater injections for comparison (placebo).  It was very important to compare side effects in those with vaccine to those with placebo, as it was demonstrated that 25% of kids who just got saltwater (which should have no side effects, other than some pain at the site of the shot), reported fatigue from the shot.  

Dr: Bradley: No

Dr. Ramers: As I showed in the initial slides, the numbers so far would refute your statement of ‘low rates of getting this’. It is true that children have *lower* rates of having severe cases or dying of COVID, there have been >6.5 million cases of COVID in kids,  >65,000 have been serious enough to wind up being hospitalized, and even though the death rate is very low, >800 children have died from COVID-19.  This is way higher than death rates for many other infectious diseases for which standard prevention by vaccination have been accepted and integrated into our society.  You are required in California to have proof of vaccination against 9 infectious disease in order to start Kindergarten unless you have a legitimate medical exemption.  Why should our standard for this disease be different?  How many dead or hospitalized children would be an acceptable number?  If the data showed that the vaccines were dangerous I would agree that we should be more cautious, but the safety data, when interpreted carefully and correctly, is strongly in support of these being incredibly safe vaccines, particularly at the lower dose being used in the 5-11 year age group.  I would recommend you review the publicly available slides that were discussed at the CDC ACIP meeting from 11/2 and 11/3. In particular Dr. Oliver’s slides go through the risks and benefits of vaccination, relative to other infectious diseases that your child is likely already vaccinated against. https://www.cdc.gov/vaccines/acip/meetings/slides-2021-11-2-3.html  

...Many of those deaths were children with pre-existing conditions. If a vaccinated child is infected with COVID-19, they can still spread the virus. Based on this information, what is the benefit in getting a healthy child with no pre-existing conditions vaccinated? - Evelyn

Dr. Ramers: Let me clarify a few of your statements. As I showed in the initial slides, the numbers so far would refute your statement of children having ‘minimal to no symptoms’. It is true that many children have mild ‘cold-like’ symptoms, and children do have *lower* rates of having severe cases or dying of COVID. However, there have been >6.5 million cases of COVID in kids, >65,000 have been serious enough to wind up being hospitalized, and even though the death rate is very low, >800 children have died from COVID-19. We also have no idea what will happen to the 7-8% of kids that have long-COVID symptoms including persistent brain fog and cognitive problems that may affect their learning in the future. It is also true that many of the sickest children have underlying conditions--one study found that about 68% of hospitalized kids had an underlying condition--that means 32% of pediatric hospitalizations *did not* and were previously healthy. In addition, the most common underlying conditions were asthma and obesity, which are extremely prevalent in the population. The COVID-19 death rates are way higher than death rates for many other infectious diseases for which standard prevention by vaccination have been accepted and integrated into our society. COVID-19 is now the 7th leading cause of death in children. You are required in California to have proof of vaccination against 9 infectious diseases in order to start Kindergarten unless you have a legitimate medical exemption. Why should our standard for this disease be different? How many dead or hospitalized children would be an acceptable number? If the data showed that the vaccines were dangerous I would agree that we should be more cautious, but the safety data, when interpreted carefully and correctly, is strongly in support of these being incredibly safe vaccines, particularly at the lower dose being used in the 5-11 year age group. I would recommend you review the publicly available slides that were discussed at the CDC ACIP meeting from 11/2 and 11/3. In particular Dr. Oliver’s slides go through the risks and benefits of vaccination, relative to other infectious diseases that your child is likely already vaccinated against.

https://www.cdc.gov/vaccines/acip/meetings/slides-2021-11-2-3.html Finally, regarding whether vaccinated individuals can still become infected with a breakthrough infection and spread the virus. You are correct that breakthrough infections are happening, and no vaccine is perfect. However, the available evidence suggests that vaccines are the most effective way to reduce the likelihood of infection, vaccinated individuals shed the virus for a shorter period, their viral loads decline faster, and they are less likely that unvaccinated people to spread to household contacts. Not perfect, just the best tool we have to prevent the 7th leading cause of death in children, reduce likelihood of infections, transmissions, and outbreaks, and keep the schools open.

Dr. Ramers: We have seen that even in areas with high vaccination rates (for example in some Northeastern states or European countries with 80% vaccination rates), that surges can still occur, largely fueled by a relaxed approach to masking and distancing and by unvaccinated individuals.  I think the phrase ‘pandemic of the unvaccinated’ is a little strong since it doesn’t account for breakthrough cases, but what is true is that moving forward, we will continue to see the most severe cases and deaths in the unvaccinated.  As I mentioned, I don’t think that there will be any one thing that will get us out of the pandemic, but rather we will need to use a combination of things. Vaccination and masking are by far the best things we have to prevent infections and to prevent transmission. They’re not perfect, but the markedly *reduce* infection, transmission, and death.  For treatment, we have monoclonals and pretty soon oral antivirals, which is good news, but these don’t do much to prevent ongoing transmission. It will be a combination of high vaccination rates, more and more natural immunity, and the conversion of COVID into a more mild illness in those who have either had it already or who are vaccinated.  This means that it will never ‘go away’ but rather be endemic and be with us for the foreseeable future, albeit as a more mild disease that will not overwhelm our health system.