Pro-vaccine messaging to patients

[rev ronin]

Just now, MediMike said:

As this is the first mRNA vaccine directed against a spike protein...do you know for sure that you can't be an asymptomatic carrier post vaccination? None of the studies have tested for infection, simply clinical symptoms/hospitalization/death.

Until we know this I believe it to be reasonable to continue masking regardless of vaccination status until we reach a much greater majority of the population who got the shot(s).

Unless you have other information? To be honest I've had a bit of COVID fatigue and haven't been following the newest and greatest.

I have no such information at all, but I disagree that masking and social distancing "just in case" is a sufficiently good idea, given the absence of affirmative evidence and the known harms from those interventions.

[MediMike]

1 minute ago, rev ronin said:

I have no such information at all, but I disagree that masking and social distancing "just in case" is a sufficiently good idea, given the absence of affirmative evidence and the known harms from those interventions.

Interesting, so you'd have no problem providing care to vulnerable populations without precautions at the moment?

I've always known you were a man of faith!

We had a breakout at a local hospital, all employees were tested. 3 were positive who had already received their 2 doses, 2 were 10+ days out, one was 15+, all three were asymptomatic. Did the lab test pick up RNA fragments floating around from a prior infection? Were they asymptomatic carriers?

I'm not sure. I find masking to be a relatively harmless intervention until we reach a point where we have widespread vaccination.

[ventana]

No Shirt

No Shoes

No Mask

No Service 

 

 

 it is that simple.  We just had a paradigm shift.   Get over it.  

[rev ronin]

22 minutes ago, MediMike said:

Interesting, so you'd have no problem providing care to vulnerable populations without precautions at the moment?

I've always known you were a man of faith!

We had a breakout at a local hospital, all employees were tested. 3 were positive who had already received their 2 doses, 2 were 10+ days out, one was 15+, all three were asymptomatic. Did the lab test pick up RNA fragments floating around from a prior infection? Were they asymptomatic carriers?

I'm not sure. I find masking to be a relatively harmless intervention until we reach a point where we have widespread vaccination.

If I'm providing care to elderly patients? I'd be happy to. Worked a 24 yesterday, only time I wore a mask was in an older patient's house--although none of the residents were masked and all had had two doses too.

If I'm just walking around? Why would I? As far as I have read there is just a theoretical idea that asymptomatic transmission could occur despite vaccination. I'd much rather use my lack of mask as a talking point to evangelize on behalf of the mRNA vaccines.  I might run over someone in my car, and yet I still drive. I might supply narcotics for an overdose, and yet I risk assess and prescribe appropriately based on my best judgment anyways. We can't ensure bad things don't happen, and if anyone has an RCT running, I'd be happy to listen to the published results.

ETA: And the vaccine pretty much guarantees that Covid-19, in any of its variations, won't kill me.  That's a pretty good reason to go back to acting normally.

[Reality Check 2]

Hi there 

I fell of the grid for a while for multiple reasons. Nothing critical but a lot at once. 

A tad disturbing to see that the conversations here are still beating the dead issues over and over.

I have received both Moderna vaccines - the second one kicked my butt. Temp up to 100.4 for a day and then 99.4ish for another day, nausea, some weird dizziness, fatigue and my arm throbbed like no other. Some headache but that could be the computer system at work. Can't remember a day of my life without nasal congestion and allergies - so who knows on that one. 

I have not knowingly had COVID prior.

THIS article does a pretty good job of discussing the second vaccine whammy effect:

https://www.theatlantic.com/health/archive/2021/02/second-vaccine-side-effects/617892/

Two of my kids were vaccinated for work - in their 20s - minimal reactions. Folks in the 50ish range seem to get whammed the hardest. Struggling to get hubby who works in school district vaccinated. Washington is SUCKING at vaccinating school staff. 

YES, I will still wear a mask and maybe double.

NO, I will not go to a restaurant, movie theater or group gathering.

YES, COVID is still out there - mutating and finding ways to still kill people.

My county is FINALLY at an R value of less than 1 and a 12% drop in positive tests and we have vaccinated a ton of folks. County = 500K ish in population.

It is safe - HELL NO. 

Stuff is opening back up and it is wrong. We will spike again.

So far, my veterans are 98% ALL OVER the vaccine to the point of yelling at me if their age bracket isn't up to call yet.

I don't have to advertise too much but tell them all and tell them reactions are worth it.

I would wear a button if I had one but I still telework - so, not too much to advertise.

Our hospital is concentrating on vaccinating vets and our face to face is still pretty limited as we borrow and steal staff to vaccinate. 

The day will come when I am back in clinic full time - no idea when that will be.

Likely be in masks for another 9-12 months and I don't care. Worth it. Paradigm shift and life goes on. 

COVID is real. It is unpredictable and kills people when you don't expect it to.

The vaccine is worth it - if I protect ONE person or reduce infection by ONE - totally worth it.

The science is real.

Aren't you glad I came back............

 

[MediMike]

4 hours ago, rev ronin said:

ETA: And the vaccine pretty much guarantees that Covid-19, in any of its variations, won't kill me.  That's a pretty good reason to go back to acting normally.

The quoted statement is what concerns me. Wouldn't be worrying about it killing you, it's the patients I'm worried about.

If you're in the midst of vaccinated folks then I agree in principle that there is little to no danger. If wearing a mask group shames enough of the borderline idiots who are iffy about wearing one then I've got no problem doing that.

Further transmission leads to further mutation, and if it keeps up the risk of a strain popping up that's resistant to the vaccine(s) gets higher. 

Your argument about driving your car/prescribing is a total false equivalent and you know that. I'm actually a little ashamed for you that it was even thrown out there. You know your ability to drive your car and can control what you prescribe. Do you know what your risks of transmitting the virus is to another person? Can you control that?

[LT_Oneal_PAC]

20 hours ago, rev ronin said:

If I'm providing care to elderly patients? I'd be happy to. Worked a 24 yesterday, only time I wore a mask was in an older patient's house--although none of the residents were masked and all had had two doses too.

If I'm just walking around? Why would I? As far as I have read there is just a theoretical idea that asymptomatic transmission could occur despite vaccination. I'd much rather use my lack of mask as a talking point to evangelize on behalf of the mRNA vaccines.  I might run over someone in my car, and yet I still drive. I might supply narcotics for an overdose, and yet I risk assess and prescribe appropriately based on my best judgment anyways. We can't ensure bad things don't happen, and if anyone has an RCT running, I'd be happy to listen to the published results.

ETA: And the vaccine pretty much guarantees that Covid-19, in any of its variations, won't kill me.  That's a pretty good reason to go back to acting normally.

I can see where you’re coming from and agree evidence should be followed. I even went on a short tirade after I saw that it was recommended we quarantine if >3 months from vaccination by the CDC guidelines. I took a step back and thought about it from a different perspective. I will not get severe disease, but the evidence has shown that it doesn’t not completely eliminate infection. Thus I may still spread it and give it to someone who does get severe disease.  Your analogy about driving and other actions isn’t perfect. You may hit someone with a car while driving, this doesn’t mean you don’t drive, but it does mean you don’t drink alcohol, use a blinker, turn on lights in the rain, give pedestrians the right of way, and generally follow the rules of the road as a precaution against hitting someone. That’s all a mask is, a precaution. Now it’s one less for yourself and more for others. Once all people who want the vaccine get it, and sounds like there will be quite a few left over doses at this rate, I think then it will be safe to say masking is unnecessary.

[ohiovolffemtp]

I saw an article in one of the email summarizers like Medscape yesterday that said at least 4 COVID-19 positives - all asymptomatic, have been identified in Oregon in persons at least 14 days post their 2nd vaccine dose (I don't recall if it identified which manufacturer).  So, it is at least possible that a vaccinated person could be an asymptomatic carrier.  I don't think there was any measurement of whether these persons where shedding enough virus to be a risk to others.  But, this does sound like a reason to continue wearing masks even if you're 14 days out from your 2nd vaccine dose.

I am whenever I enter a patient room in my ED or in the IP unit.

[MediMike]

@rev ronin btw I didn't mean to sound so harsh remarking about the false equivalency thing, humor rarely translates well on here.

[ventana]

A few points. 
 

1) no test is 100% all the time every time.   I have listened to doc’s from the local hospital all the way to head of DPH just say a positive is a positive.  This is a true disservice to the science of medicine

2) the tests are also approved under EUA (so no solid reliable proof they do what they claim)

3) it is safer (but I believe wrong) to simply go along with the positive test being a true positive 

4) we do not yet have a commercially available culture - which might answer the question of “are you infective”

5) personally I have seen 3-5 false positives.   Two of them were in a nursing home I run.  Took about 10 days to finally get ahold of the Quest pathologist to review findings.  In this case there were >5 negative tests before positive, single positive, then >2 negative tests after the positive (3 day intervals after positive). After talking to Pathologist his only conclusion was a false positive likely due to handling error in chain of custody (funny he still didn’t talk about sensitivity/specificity)  the state epidemiologist was very interested in my findings and admitted they were looking into false positives (quietly)

 

 

so we have a test we really are not all they sure about (think pretext probability)

no test to accurately determine infectivity

public health officials to scared to admit the testing shortcomings (and I can’t think of a situation where I would go against a positive until proven it is false with sequential testing or a true culture - neither of which would likely be completed before quarantine is done)

society that is tired of being lied to and just wants simple answers

 

so it is clear as mud, but my first questions on post vaccination positives is what is the culture results? What is the viral load? And are they infective?  None of which we can answer currently   

 

the point being is we still have to be cautious with masks and social distancing till enough in society are protected because we don’t have the answers to the above questions.  
 

[TheFatMan]

15 hours ago, MediMike said:

As this is the first mRNA vaccine directed against a spike protein...do you know for sure that you can't be an asymptomatic carrier post vaccination? None of the studies have tested for infection, simply clinical symptoms/hospitalization/death.

Until we know this I believe it to be reasonable to continue masking regardless of vaccination status until we reach a much greater majority of the population who got the shot(s).

Unless you have other information? To be honest I've had a bit of COVID fatigue and haven't been following the newest and greatest.

To add to this, we don't know how effective these vaccines are for the new variants....Which I would argue is a good reason to continue wearing a mask. There are plenty of anti-maskers, anti-vaxxers, and large gatherings that will continue to help drive mutation so making is still important.

[MediMike]

3 hours ago, ventana said:

 4) we do not yet have a commercially available culture - which might answer the question of “are you infective”  

Huh. I wasn't aware of this, was of the understanding that we were able to culture. In fact had a consultant the other day express concerns about a patient who has tested positive for 70+ days so they sent a culture and nothing grew.

Filthy liar? Maybe.

[ventana]

Like I said, no commercially available culture.  Sure a lab can culture for just about anything but nothing like a 2 day throat culture widely available and used.....

 

 

[rev ronin]

11 hours ago, TheFatMan said:

To add to this, we don't know how effective these vaccines are for the new variants....Which I would argue is a good reason to continue wearing a mask. There are plenty of anti-maskers, anti-vaxxers, and large gatherings that will continue to help drive mutation so making is still important.

If you want to talk about making everyone wear N95's, then sure, but cloth masks do little to nothing to protect the wearer from getting infected, although they do seem to limit the initial viral dose and hence infection severity.

Absence of evidence is not evidence of absence, so I would say that the burden of proof is on those advocating for the continued use of questionably effective NPIs, when we have vaccines on a rapid rollout. Covid NPIs are clearly effective against seasonal influenza, so why don't we just keep doing them year round indefinitely?  Because each countermeasure has a cost.

[TheFatMan]

13 hours ago, rev ronin said:

If you want to talk about making everyone wear N95's, then sure, but cloth masks do little to nothing to protect the wearer from getting infected, although they do seem to limit the initial viral dose and hence infection severity.

Absence of evidence is not evidence of absence, so I would say that the burden of proof is on those advocating for the continued use of questionably effective NPIs, when we have vaccines on a rapid rollout. Covid NPIs are clearly effective against seasonal influenza, so why don't we just keep doing them year round indefinitely?  Because each countermeasure has a cost.

Not going to get into the effectiveness of masks and transmission - I think that has been covered enough.

I think it is reasonable to assume that our vaccines aren't effective for the new variants until we know more about it. I understand that there isn't evidence to think that they won't be effective right now, but I'd say an abundance of caution would be useful if it means avoiding a disaster (especially with such a small intervention). I don't think it would take very long to figure out whether they work - I haven't been following it too closely lately but I think I saw something about Pfizer and one of the variants already. Masks are an easy measure to take to continue protecting ourselves and each other with no real harms. 

Correct me if I'm wrong, but I don't think anyone was advocating for year round masking. Although I don't think it would be a bad idea to start doing it during the winter anyway (not making it a requirement). 

[rev ronin]

Fundamentally, I don't mind being alone on this one, for the reason that I'm pretty sure that I'm the only one in the conversation who has both been a medical professional and a risk management professional.  When I say "every countermeasure has a cost," that's something everyone can intellectually assent to, but how many of you have actually been substantially responsible for influencing a Fortune 100 company's security and countermeasures policy?  I mean, I've gone through and calculated how much, in real dollars, a 90-day password change policy costs: not just in terms of call center capacity or IT personnel costs, but also including the hassle effect on all employees, as well as the fact that there are a finite number of 'rules' which humans will amenably endure.

With that background, when someone else asks "what's the cost/harm" of a particular NPI, my response is "Almost certainly orders of magnitude higher than you can fathom."

[MediMike]

1 hour ago, rev ronin said:

Fundamentally, I don't mind being alone on this one, for the reason that I'm pretty sure that I'm the only one in the conversation who has both been a medical professional and a risk management professional. 

While I'm not a risk management profession I did stay in a Holiday Inn Express last night and can tell you that the cost of changing your password is magnitudes less than the cost of a loss of life, so I don't really see your specific experience playing a major role here. 

No one is disagreeing that the cost to the economy, social interaction, children's education and fundamental growth is high.  But a gradual return to normal as infections go down and individuals get vaccinated makes sense. 

Can you explain why this systematic approach to reopening is a bad idea? We are about 2 months into immunizations for specific populations, you think that's enough to toss it all aside? Should you carry your immunization card around to show you don't have to wear a mask or should nobody wear a mask anymore? How do you differentiate between them? Do you believe there is some contribution of groupthink in ensuring individuals continue to mask and socially distance?

[TheFatMan]

What Mike said. To quote someone from early in the pandemic, "we can rebuild the economy, but we can't resurrect people."

I see how requiring masks is costing hospitals/the government money, and I even saw that more shortages are coming. I also know that another surge in cases that leads to lockdowns will cost a hell of a lot.

However, I genuinely do not understand what individuals choosing to purchase and wear their own masks has to do with cost or harm. I'm not being snarky here - really want to know what I might be missing. Masks are readily available and affordable. There are now mask fitters which make them even better, and these are cheap too. I've double masked, it isn't any worse than wearing a single mask (except they tend to slide up your nose more...gotta figure that part out). I know you said you don't believe they prevent the spread, but if you do believe they reduce severity don't you think the minor cost/inconvenience is worth it? Or am I missing something here? 

 

[rev ronin]

6 minutes ago, MediMike said:

Can you explain why this systematic approach to reopening is a bad idea? We are about 2 months into immunizations for specific populations, you think that's enough to toss it all aside? Should you carry your immunization card around to show you don't have to wear a mask or should nobody wear a mask anymore? How do you differentiate between them? Do you believe there is some contribution of groupthink in ensuring individuals continue to mask and socially distance?

1. "Systematic" neither implies risk-based nor science-based.  "There is nothing in this world so permanent as a temporary emergency" --Heinlein. The number of issues with ongoing "emergency" powers are legion. Do you trust your government to do the right thing? What about if the other guy had won?  Enforcing conformity on Americans, who are hopelessly individualistic, is itself a significant cost with probable secondary effects that haven't really been effectively considered, let alone modeled.

2. Have you stopped beating your wife lately? I mean, not literally, but if you expect me to answer that sort of a question, you need to phrase it in a way that doesn't assume the antecedent.

3/4. False dichotomy.  You can surely think of other solutions--why dive to the extremes?

5. This is another big issue. We have trust issues, with people NOT believing in vaccines, which have scads of really good evidence, compared to masking and social distancing which seem to have good evidence of some impact, but all the honest epidemiologists admit it is near impossible to quantify the exact extent of such impact, or apportion it appropriately between countermeasures.

[MediMike]

2 minutes ago, rev ronin said:

1. "Systematic" neither implies risk-based nor science-based.  "There is nothing in this world so permanent as a temporary emergency" --Heinlein. The number of issues with ongoing "emergency" powers are legion. Do you trust your government to do the right thing? What about if the other guy had won?  Enforcing conformity on Americans, who are hopelessly individualistic, is itself a significant cost with probable secondary effects that haven't really been effectively considered, let alone modeled.

2. Have you stopped beating your wife lately? I mean, not literally, but if you expect me to answer that sort of a question, you need to phrase it in a way that doesn't assume the antecedent.

3/4. False dichotomy.  You can surely think of other solutions--why dive to the extremes?

5. This is another big issue. We have trust issues, with people NOT believing in vaccines, which have scads of really good evidence, compared to masking and social distancing which seem to have good evidence of some impact, but all the honest epidemiologists admit it is near impossible to quantify the exact extent of such impact, or apportion it appropriately between countermeasures.

1) Neither does your approach of "I'm vaccinated so I don't have to wear a mask."  You have no idea of the risk behind that, nor the science.  Taking an approach to reopening based on a reduction cases in the community appears to be working and likely has more science behind it.  Epidemiology isn't my specialty, but the folks running this show do seem to have some interest in that area. I do trust my state government and the current administration.  No I didn't trust the last administration's approach. 

2) You want to stop masking based on the current vaccination status of individuals.  You are figuratively beating your wife.  Or are you saying you never wore a mask (i.e. never beat your wife?)

3/4) You are a proponent of not masking if vaccinated, what is your approach to proving a vaccinated status?

5) We have gotten to the point where more people are accepting of masks, which as you note have good evidence of some impact.  It took us a long time to get here and I am willing to bet that if you start de-masking many individuals who aren't vaccinated will follow suit as that societal expectation is no longer there leading to a potential increase in cases, strain mutations and lessening of the effectiveness of vaccines.  I'm not sure what your concerns are regarding "risks" of masking that would outweigh that?

[rev ronin]

How many net deaths will happen if we stop expecting vaccinated individuals to mask?  You can't possibly answer that question with any degree of certainty, can you? If you can't, you can't run a cost-benefit analysis.  If you can't run a cost-benefit analysis, you have no business advocating for an intervention, let alone mandating it. I mean, unless you want to abandon the pretense of science and just admit it's about power and enforcing conformity.

Masks and social distancing suck: they have minimal benefits and high costs.  Vaccines don't suck: they have modest costs and HUGE benefits. The faster we jettison countermeasures that have been superseded by more effective ones, the better off we are.

[MediMike]

In this situation since masking is the accepted norm at the moment you appear to be advocating for an intervention, i.e. the stopping of wearing a mask or a "demasking" if you will. 

What is the risk of transmission while vaccinated? Give me some science here man, if you don't know then you see to be abandoning the pretense of science and admitting that it's just a stubborn desire to do what you want.

What is the risk of wearing a mask? The benefits seem to be higher than you are arguing. I asked earlier and didn't get a response.

Your enforcing conformity argument is pretty weak.  When we're talking about public health I believe conformity to be of paramount importance.

[ventana]

18 hours ago, rev ronin said:

How many net deaths will happen if we stop expecting vaccinated individuals to mask?  You can't possibly answer that question with any degree of certainty, can you? If you can't, you can't run a cost-benefit analysis.  If you can't run a cost-benefit analysis, you have no business advocating for an intervention, let alone mandating it. I mean, unless you want to abandon the pretense of science and just admit it's about power and enforcing conformity.

Masks and social distancing suck: they have minimal benefits and high costs.  Vaccines don't suck: they have modest costs and HUGE benefits. The faster we jettison countermeasures that have been superseded by more effective ones, the better off we are.

Disagree strongly

 

Masks do not have a high cost, and EBM should trump cost-benefit analysis

Rev - very little of our treatments are EBM with good double blind placebo controlled data

Masks for the public are cheap - come on we live in a society of excess - we can pretty much all afford a mask and those that can't can make them, or get from any number of places for free.  There is a slight (and I mean slight) inconvenience factor but that is it.

 

I am strongly for masking and I see absolutely zero reason not to......  your personal liberties do not trump my ability to protect my family.  With a child that has had issues in the past I am still respectful of covid and precautions....

[TheFatMan]

I think it can be confidently said that masks and social distancing don't suck.

• Link to 70 mask studies showing benefit
• Nature article on mask effectiveness
• "wearing of face masks in public corresponds to the most effective means to prevent interhuman transmission"
• "Face mask use by the primary case and family contacts before the primary case developed symptoms was 79% effective in reducing transmission"
• Another epidemiological study
• Carnegie Mellon article
   
• social distancing works (and dramatically)
• Both shelter-in-place orders and closures of restaurants, bars, and entertainment-related businesses substantially slowed the spread of COVID-19.
• more social distancing

This is from a study of 134 countries that showed those with a nationwide and coordinated social distancing response reduced COVID-19 transmission by 65% in two weeks, preventing 1.57 million COVID19 cases.

 

[MediMike]

1 hour ago, TheFatMan said:

I think it can be confidently said that masks and social distancing don't suck.

• Link to 70 mask studies showing benefit
• Nature article on mask effectiveness
• "wearing of face masks in public corresponds to the most effective means to prevent interhuman transmission"
• "Face mask use by the primary case and family contacts before the primary case developed symptoms was 79% effective in reducing transmission"
• Another epidemiological study
• Carnegie Mellon article
   
• social distancing works (and dramatically)
• Both shelter-in-place orders and closures of restaurants, bars, and entertainment-related businesses substantially slowed the spread of COVID-19.
• more social distancing

This is from a study of 134 countries that showed those with a nationwide and coordinated social distancing response reduced COVID-19 transmission by 65% in two weeks, preventing 1.57 million COVID19 cases.

 

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