Hospitalist Robert Wachter, MD, MACP, said that only three of his behaviors have changed or will change since getting the COVID-19 vaccine. None of them are related to work.
“I did get a real haircut, I would go and see the dentist, which I've not done, and when the cases come down a fair amount, I will feel comfortable flying in a way that I wouldn't have a few months ago,” he said in February. “Those are the only three that I think I would do differently.”
On Dec. 11, 2020, the FDA issued the first emergency use authorization (EUA) allowing the Pfizer-BioNTech COVID-19 vaccine to be distributed in the U.S. The EUA for the Moderna COVID-19 vaccine soon followed on Dec. 18, 2020. (The Johnson & Johnson vaccine received an EUA on Feb. 27, after the reporting for this article.)
The vaccines offer true risk reduction and very good protection against the virus, but as of February, data on their effects on transmission were only beginning to surface, said infectious diseases physician Joshua Barocas, MD, during an Infectious Diseases Society of America (IDSA) media briefing.
“We are starting to gather actual evidence from some of the trials and some of the retrospective studies about what they do for transmission,” he said. “What many of us have felt for a while is that they probably decrease transmission. The fact is now we're getting data on that.”
But at the individual level, Dr. Barocas, an assistant professor of medicine at Boston University School of Medicine, still wears a mask despite being vaccinated. “It's important for me because I know that it doesn't necessarily break the entire chain of transmission,” he said. “It probably does a little bit, but it's important for me to make sure that I'm protecting other people.”
Until research can show that a vaccinated person is incapable of catching the virus and spreading it to someone, hospitalists will need to stay vigilant, said Dr. Wachter, who is professor and chair of the department of medicine at the University of California, San Francisco (UCSF), Medical Center. “We might be a little comfortable engaging in a few low-risk activities, but we still have to treat the possibility that we could give it to someone else as being very real,” he said.
Thus, as hospitalists received their first and second doses of COVID-19 vaccine, life in the hospital went on largely unchanged—apart from some newly felt emotions.
Same as it ever was?
Dr. Wachter started on service three days after receiving his first dose of vaccine on Dec. 18, 2020. But due to a surge of COVID-19 patients, he didn't feel any safer.
The data at the time suggested that he was about 50% protected by the end of two weeks of service, “but it was also at a time that we were having our biggest surge in San Francisco, so the chance that a patient was going to be positive was higher than it had been the last time I was on,” he said. “To me, those things cancel each other out.”
The second dose brought a greater feeling of safety. “Afterwards I felt more comfortable that I'm not going to die,” Dr. Wachter said, “which feels good.”
For patient encounters after vaccination, he wore an N95 with a surgical mask over it. “It seems like most people now are double masking during patient encounters, still being really safe, and that's what I did when I saw patients,” said Dr. Wachter, who spends about one month per year doing inpatient care.
Another hospitalist, Christopher Moreland, MD, MPH, FACP, said in February that he hasn't changed anything about his personal or professional practices since getting his first dose of vaccine on Dec. 15, 2020. “While it is humanly tempting to let down our guard, my family and I continue to mask, handwash, and socially distance as we have been,” he said.
Care processes in the hospital remain unchanged, including careful use of personal protective equipment (PPE), said Dr. Moreland, an associate professor in the department of internal medicine at Dell Medical School and a hospitalist at Dell Seton Medical Center in Austin. “Even with patients with negative COVID tests, we continue to handwash and use face masks with eye protection,” he said.
Likewise, vaccination status did not change any policies related to PPE for clinicians at Virginia Mason Medical Center (now Virginia Mason Franciscan Health) in Seattle, said hospitalist and chief medical information officer Barry Aaronson, MD, FACP. “We've been fortunate to have an adequate supply of PPE,” he said, “so it didn't change personal behavior, it didn't change hospital behavior, and it certainly didn't change hospital PPE policy.”
Even in the preoperative medicine clinic at Oregon Health & Science University in Portland, where Avital O’Glasser, MD, FACP, an associate professor of medicine in the division of hospital medicine, serves as medical director, care pathways and patient flow are no different postvaccination. “Our clinic performs the majority of preop/preprocedure screening swabs, and patients who have received the vaccine still need to get screened before their surgeries,” she said, adding that she still wears a mask and face shield for face-to-face patient visits.
It's still unclear how long PPE and other COVID-19 mitigation strategies will continue. During the IDSA media briefing, a reporter asked whether there might be a permanent cultural shift within hospitals that might lead everyone to wear masks for good, since there has also been a decrease in flu cases during the pandemic.
There is discussion of that question in EDs and on hospital wards, Dr. Barocas noted. “The larger question is, is everyone going to need a break?...I know that I'm going to need to retire my masks at some point in the future for a little bit,” he said.
The pace of potential change has also been affected by stumbling blocks encountered by COVID-19 vaccination programs.
Initially, there was some concern that too many hospital employees may call out from work due to side effects from the vaccine, particularly after the second dose. “That's why we didn't have anybody get the second dose the day before they work,” said Dr. Aaronson. The hospitalists interviewed for this story generally reported transient, if any, side effects from vaccination, as well as deliberate vaccination timing to ensure enough time to recover.
There is also the issue of vaccine hesitancy. In a survey conducted last autumn, fewer than half of 609 health care workers at University of California, Los Angeles, Health reported that they believed a novel coronavirus vaccine would protect them against COVID-19, according to results published as a letter in February by Annals of Internal Medicine. Compared with prescribing clinicians, other health care workers were about 20% to 30% more likely to delay or decline a coronavirus vaccine after controlling for other demographic factors.
Similar research, published by Clinical Infectious Diseases in January, found that physicians are particularly likely to support vaccination. In a survey of New York health care workers, 80.4% of physicians and scientists were planning to be vaccinated, compared to 57.5% of clinicians overall.
These findings align with what Dr. Wachter has seen at UCSF. “I've not heard a physician choose not to take [the vaccine], and it looks like the rate of uptake is well into the 80% to 90% range,” he said. “At least from the last time I saw that being analyzed, the people who had not taken it tended to be our nonclinicians, although sadly it looks like the prevalence of nurses choosing not to go with it, at least in the beginning, was higher than among the doctors.”
Reflections on a miracle
For many hospitalist physicians, receiving the vaccine brought a variety of emotions.
In Dr. Moreland's case, he found himself unusually enthusiastic about getting the shot. “Believe me, no one has ever seen me excited to get a needle in the arm. It was invigorating in a way, like an infusion of hope,” he said. “That was sparked by seeing hospitalist colleagues abuzz with their own anticipation all morning.”
For Dr. O’Glasser, who received her first dose on Dec. 24, 2020, even reading the vaccine confirmation email felt like a catharsis. “I didn't cry when I got the vaccine itself, but I did burst into tears when I got the late-night email with the, ‘Heads up, your clinic team will be getting appointment spots in two to three days,’” she said. “I received it on the last work day of 2020 for me, so there was a lot of emotion bundled in with that and bringing some small degree of closure to 2020.”
Even before he was vaccinated, Dr. Aaronson said gratitude was top of mind. “The miracle of human ingenuity, the toil, and all the planning and different people that were involved to get that to my hospital is just mind-boggling,” he said.
When Dr. Aaronson received his first dose on Dec. 27, 2020, he held up a homemade thank-you sign as he took a photo and also posted a letter of thanks to science on social media, which was published in The Seattle Times. “It was miraculous that all the pieces needed to develop and distribute a vaccine fit together so quickly. That is at least partially because the scientists who developed the vaccine were able to stand on the shoulders of those whose work had come before,” he said. “For instance, scientists were working on messenger RNA vaccines in animal models long before anybody heard of COVID. Therefore, they were able to proceed rapidly to human trials.”
Creating and deploying effective vaccines on such a short timeline could be considered medicine's own personal moon launch, Dr. Aaronson said, although perhaps it's not as awe-inspiring for some. “When we first launched a rocket to the moon, people saw the flames of the rocket ship launch and saw astronauts walking on the moon. Those visuals made it easy to appreciate what an amazing accomplishment that was,” he said. “But getting 0.3 cc's of clear liquid jammed into your arm? While conceptually as amazing as a moon launch, when it comes to the optics, it is not as easy to appreciate the epic accomplishment.”
Dr. Wachter recalled holding Grand Rounds with vaccine and virology experts in April 2020 and asking them when a vaccine might be available. “The answer was, ‘Maybe by spring 2021.’ And how effective will it be? The answer was, ‘Maybe 70%, 75%—that would be great,’” he said. “So the fact that we had two vaccines that were 95% effective, and essentially 100% effective in preventing severe cases, and had them rolling out in December was a miracle. Absolutely unbelievable.”