Last Updated: January 15, 8:47 a.m.
Earlier this week FlaglerLive launched the “Ask the Doctor” column, by Dr. Stephen Bickel, the medical director at the Flagler and Volusia Counties Health Departments. Below are his answers to 34 questions submitted in the first two days, most of them grouped by themes.
The questions broke down into three groups, with 14 questions about the second dose of the coronavirus vaccine, 11 more general questions about when the vaccine would be available and the logistics of making appointments, and nine more specific questions on a variety of subjects. Dr. Bickel addresses the first two sets in two separate answers, then tackles the nine questions individually.
Dr. Bickel, featured almost weekly on WNZF’s Free For All Friday program since last March to update the community on the coronavirus pandemic and answer questions, will be doing so on a rolling basis here. The questions don’t have to be limited to the pandemic.
You are invited to submit your questions using the form below, or by email, or in the comment section below. The entire list of questions will be archived, indexed and linked to their answers on a separate page, here.
As Dr. Bickel describes it, “the “Ask the Doctor” column will be a semi-regular feature of FlaglerLive, the frequency of which will depend on the volume of questions we receive. The updated timestamp in red at the top of the page, will indicate when new question s have been answered.
Please feel free to ask any medical question you want, and I will do my best to answer it. In preparing my answer to your question, I may consult with some of my medical specialist colleagues or review the medical literature in order to come up with the best possible answer.
“Please limit your questions to general medical advice—I can’t give you specific medical advice since I don’t know your individual medical history. The emphasis of this column will be to provide information based on current scientific evidence while keeping speculation and politics to a minimum. If I don’t know something or the medical literature really doesn’t have much to say on a particular topic, I will tell you that.
“The fields of medicine and science in general are always advancing and we don’t have all the answers, but I will try to come up with something helpful for every question I receive, even our knowledge in an area is limited. At first a lot of the questions may be about Covid-19, but they don’t have to be, and any area of medicine is fair game for this column.”
The inaugural installment of the “Ask the Doctor” column, also about vaccines, is available here.
By Stephen R. Bickel, M.D.
The second dose: We received 14 questions in one way or another related to readers’ concerns about securing a second dose of the Moderna vaccine. Many residents, like Mark Ellison and Judith Patterson, asked how they could secure their second shot. One asked: “Will we be able to get our second shot ahead of new vaccine seniors or will we have to scramble to get ours?” Others asked: “How far past the target date is it considered viable to receive the 2nd shot for it to still be effective?” Paul Taylor and others asked if a single dose of the Moderna vaccine provides any immunity protection, or, as Bob Cuff put it, “if the second dose is delayed beyond the 3-4 weeks recommended, how long can a person who receives the first dose wait for the second without compromising the vaccine’s potency?” Another reader asked: “At what point is the first shot worthless to reach highest level of protection, and you have to start over with two shots 4 weeks apart to get full protection?” And Sharon Sejda asked: Are the first and second doses of the Moderna vaccine the same? Yet another reader asked: “I have contacted Mayo Clinic and Advent, both saying they will only provide second vaccine doses to those who received the first dose from them. If Flagler County isn’t going to have any second doses at the appropriate time, where can we turn?”
These are all excellent questions and it’s not surprising there’s some confusion especially about the second dose given how rapidly the vaccine availability landscape has changed in the last two weeks. As far as vaccine availability in Flagler County is concerned, things are still in a state of flux right now although there’s starting to be some clarity. There have been questions about availability on the national level as well as the production schedules of the two companies making the vaccines. Also, there has been some uncertainty and opacity about how the vaccines are being allocated on the national level to the states and then on the state level to the counties. There has also been some debate about priorities, i.e., which groups should have the highest priorities for getting vaccinated. In this regard, the CDC has produced guidelines of how they think the vaccine should be distributed, but the states have the final say, and with various groups promoting various strategies it’s no wonder that people have been somewhat confused.
So let me tell you the current status of vaccinations in Flagler County. Locally in our county, our Health Department did not receive any vaccines this week but we will start receiving them again next week. This is the latest information so if you heard anything different earlier this week, things have changed. As of now there will be vaccines available starting next week for the county health department to distribute. Also, our four local Publix pharmacies started receiving vaccines this week and will continue to receive them going forward.
In addition, for several weeks now Advent Health has been receiving vaccines that they primarily used for their healthcare workers and their staff but they’re starting to distribute vaccines to the general population (this would be the over 65 age group)–the first site where they did this is in Orlando but we have been told that in the not too distant future their Daytona Beach hospital will start vaccinating the over 65 general public.
Our nursing home and assisted living facility residents and staff are also high-priority for vaccination, but they have a separate program through CVS and Walgreens (although some changes are being made to this program). Right now the top priority group for vaccinations (besides nursing homes and assisted living facilities) consists of healthcare workers and adults over the age of 65. Some of you have asked about chronic conditions–as of now, prioritization for this group is not entirely clear but it may soon change and the state seems to be supportive of vaccinating this group.
In terms of the second dose it’s no wonder there has been some confusion about this because various proposals have been bandied about regarding whether second doses should be prioritized or whether we should try to get as many first doses administered as possible. You may have even read some of this debate in the media about whether we should put off giving people the second dose indefinitely. However, this is not what the FDA recommends and they have gone on record stating as much. These vaccines were studied in two dose regimens with specific intervals between the doses, and these are the regimens that have been shown to be so highly effective. Because of this the FDA wants to continue with that exact vaccination protocol.
The CDC has issued guidelines available about what it recommends in terms of priority groups, but keep in mind in terms of priorities it’s the states that get to decide, so the CDC makes recommendations but the states are in charge of how the vaccine actually gets distributed. Getting back to the second dose there are now people who are eligible for their second doses (those who received their first Pfizer vaccine three weeks ago or their after the first Moderna vaccine four weeks ago), and in Florida they are going to be prioritized to get their second dose. In Flagler County the Department of Emergency Management (EOC) has a record of all the people who have gotten their first doses (and when they received them), and if you belong to this group they will contact you the week before it’s time for you to get your second dose.
A couple more points regarding vaccine availability–national distribution is going to increase starting next week when vaccine that has been held back is going to be released in order to provide enough vaccine for second doses for everyone who has already received a first dose. On the county level in Florida, it was confirmed today that all local county health departments will receive their inventory of 2nd doses on Friday of the week before the 2nd doses of vaccine are scheduled to be administered. Hopefully this process will go smoothly. There is also going to be a ramp-up in production taking place for both the Moderna and Pfizer vaccines. The latest information available on their production schedules is that Pfizer plans to make available 70 million doses of vaccine (for use in the U.S) by June 30 and 100 million additional doses by July 31, and Moderna plans to make available 100 million doses of vaccine by the end of March and an additional 100 million doses by the end of June.
Other vaccine information–the Department of Emergency Management (EOC) of Flagler County currently has 4000 people on a call back list for distribution of the first dose of vaccine, so they will be keeping that list and contacting people on their list when more vaccine is available. There was an old system that was used to set up appointments that just got overwhelmed by the numbers, so the state of Florida is now setting up a new system that I’ve been told is functioning very well in beta tests and should be ready for mass use in the next two or three weeks. This will be the system that all the counties in the state will use going forward. People will have the option of calling in or enrolling online in the system, but either way they do it they will be in the same scheduling system, so if you called in previously and had your name put on a list you will probably be called back, but to be on the safe side should probably register with the new system once it is set up.
In terms of the dosing interval, two shots are definitely recommended rather than one shot–that hasn’t changed and that is the FDA’s original decision that came in the EUA (Emergency Use Authorization) for both vaccines which was based on randomized controlled trials that show the vaccines to be approximately 95% effective in preventing Covid disease. The recommended interval between doses is three weeks for the Pfizer vaccine and four weeks for the Moderna vaccine. Based on studies of other vaccines, there’s no particular reason to think that having a somewhat longer interval would diminish the effectiveness of the booster especially if it’s done within three months. There’s usually a sweet spot of time during which the second booster dose of a vaccine can be given and remain highly effective, not too short and not too long (between doses), but we don’t have any hard data on that for these vaccines. In terms of protection after the first dose, there was evidence in the Moderna trial that beginning 14 days after the first dose there was a 92% reduction in Covid disease which was very similar to the effectiveness of the two dose regimen. We don’t know how long this effectiveness lasts, however, and these findings were based on fairly small numbers of cases compared to the full vaccine trials, so these conclusions are considered provisional, but these findings do lend support to the conclusions that for the Moderna vaccine (and by inference for the Pfizer vaccine, where the data are more limited), protection is very good starting about 14 days after the first dose and probably persisting for at least a few months. Still, I do not recommend that people put off the second dose for too long, but a delay of up to 3 months between doses will probably not diminish vaccine effectiveness much if at all.
There also two other vaccines that are being studied actively that may soon be authorized for use in the U.S., the Johnson & Johnson vaccine and the AstraZeneca vaccine. These are expected to be reviewed and most likely approved in the next couple of months, based on data that’s already been gathered in other countries. The AstraZeneca vaccine has actually already been approved in England. We don’t know the exact timetables on this but it is entirely possible that both of these will start being available in the U.S. sometime this spring. If this happens then all of a sudden our vaccine supply will get that much better. So things are changing fast in Covid vaccine world. Just try to have a little patience and we will do all we can on our end to get these life-saving vaccines out to you.
There were 11 questions about the logistics of the vaccine or, as Ileine Hoffman put it, “Obviously the only question is where is Flagler’s vaccine? Any other question is irrelevant.” Mary Koonce asked: “Why isn’t more being done to mitigate. Are you asking for vaccines? Do you have a plan for mass vaccinations?” Why isn’t Flagler County getting more? Many senior citizens asked why they are not better informed about when the vaccine will be available. Loren Harlan asked: “Both my husband Bruce 66 and myself 59, Type 1 Diabetic would like to obtain the Covid Vaccines ASAP. Today, January 12, Dr. Azar announced a “change” in recommendation of disbursement, to include those 65+and those with pre existing conditions. We have been locked down since the onset for our safety as well as to not spread the virus. Will Dr. Azars and the CDC directive be followed? If not, where may we obtain our vaccines?” There were also questions about whether AdventHealth Palm Coast will offer vaccinations.
Some of you asked why Flagler County didn’t get more vaccine. This is complicated and so many factors are involved that it’s hard to say exactly why. We have consistently lobbied for as much vaccine as possible as soon as possible–and I can assure you that our health officer, Bob Snyder, is a passionate advocate for our county! We learned this week from the state Department of Health that allocation criteria going forward will focus on total county population and also the % of individuals over age 65 in each county.
All we can do at this time is prepare ourselves and make sure we are ready, willing, and able to give as much vaccine as possible as soon as we get it. So far, we have given out all the vaccine we have received within a week of receiving it. Going forward, we are prepared to give out 1000 doses of vaccine a day five days a week right from the start–this would amount to 5000 doses a week. And we could quickly gear up to give 2000 doses a day seven days a week–we would only need a couple weeks to prepare ourselves for that level of vaccine distribution.
We are planning to deploy 4 vaccination teams–2 teams for the drive-through fixed site at the fairgrounds and 2 teams that would become mobile and fan out across the county on a scheduled basis and target as many organizations, areas, and facilities as possible. Our goal is to give out the vaccine as conveniently as we can as rapidly as we can–as we get more vaccine we plan to go out into the community more and more with our mobile unit–this will make it easier for people who have either limited access to healthcare or transportation challenges to get their vaccine. Our goal is to achieve “community/herd immunity” in Flagler County–and to do this we probably need to get 70 to 80% of the population vaccinated. We are totally committed to doing this if the public is willing to accept these vaccines at that level.
Some of you asked about what’s in these vaccines–the Pfizer and Moderna vaccines are both messenger RNA vaccines–they have some other ingredients in them that help stabilize the messenger RNA which is a very delicate biological material that only lasts in the body for about a day at the most–by then it has encoded protein that is used to trigger the immune response. This messenger RNA does not enter the cell nucleus and is not incorporated into our own DNA which is not affected at all by these vaccines.
This is a new vaccine method that’s based on the latest scientific developments in molecular biology, and it has a lot of potential applications. It is being monitored very carefully for side effects, both immediate and delayed, and also both minor and serious.
So far the data look very good–these vaccines do appear to cause a slightly increased rate of severe allergic reactions–but such reactions are still quite rare. If we vaccinated all of Flagler County, based on the current rates of reaction that have been noted, we would have one severe allergic reaction in the entire county because the rate is about 1 in 100,000–and these reactions can be treated rather easily with medications that we have on hand at the vaccination sites–by the way, this is why we observe people for 15 minutes after giving them the vaccine.
More Specific Questions:
I am still vomiting after a week of Covid. Is that normal? GI symptoms such as nausea, vomiting, and diarrhea are fairly common with Covid and they can certainly last a week or even longer. Although respiratory symptoms are more frequent and prominent, your symptoms are not unusual.
I’m a teacher and I am exposed to Covid every day, students get quarantined but teachers do not. I’m taking off two months because I have asthma, and I can’t wear her mask for long, and I have other health problems (I’m 58). Would I be towards the front of the line to get the vaccination? When do you think it will be available? You have two reasons to be in a high priority group–one is you are an essential worker and we thank you for that; and the other is your medical condition, asthma–so hopefully you will be able to get vaccinated very soon, but for now it’s primarily health care workers and adults over 65. There are some preliminary plans to prioritize patients with chronic medical conditions, but this is still a work in progress.
I understand that a very healthy doctor in Miami recently passed away 15 days after taking the vaccine. How are the issues of adverse reactions to the vaccine being approached. I am concerned and not convinced it is safe. As more and more people get vaccinated there are going to be a variety of conditions, some minor and some serious that develop in people after their vaccinations–and these may or may not be due to the vaccine itself. The way we assess this is to look carefully at statistics to monitor the rates of various reactions to see if there’s an increased rate in the vaccinated people. It’s hard to say what happened in this individual who unfortunately passed away since we don’t know exactly what happened, but in the Moderna and Pfizer studies so far, studies that included tens of thousands of people, there were no increased rates of any serious conditions.
I have heard that some vaccines for Covid-19 have sulfa as an ingredient. I have an allergy to sulfa drugs. Would it be dangerous for me to take a vaccine with a sulfa drug in it? [Nancy Skadden]. There is no sulfa component in either of these vaccines. It’s rather easy to get a list of all the components in these vaccines by just doing a web search for “Pfizer Covid vaccine ingredients” or “Moderna Covid vaccine ingredients”.
I have COPD, hypertension in my heard and myocardial bridging in my heart. I am scared about the vaccine affecting those to problems. Will I be okay taking it? Also what do people without texting capabilities to about making an appointment? Is there e mail address? Thank you. These vaccines may cause a relatively minor immune reaction in patients, usually limited to arm soreness or a mild fever, myalgias, or headache–but no serious cardiorespiratory reactions–so it should be quite safe for you–and given your medical problems you are at significant risk from complications from Covid so having the vaccine protect you from a Covid infection would be very beneficial for you.
From a conventional medical approach, how long does it take for a severe vitamin D deficiency to approach a normal range if a patient is consistently supplementing with vitamin D3 at high doses (8,000 to 10,000 IUs), as studies indicate that this deficiency has been found to be deadly with SARS-CoV-2 infections? What is a good maintenance dose thereafter? What if the patient doesn’t seem to be absorbing the supplement upon subsequent blood tests?
Vitamin deficiency is pretty complicated and it almost could be a separate topic on its own. If someone has severe vitamin D deficiency there’s often a medical reason for it, and in cases like that vitamin D supplementation can sometimes be difficult because the person may not be absorbing vitamin D adequately. If this is the case then close follow-up by a healthcare provider may be needed. Roughly speaking it usually takes a couple months to correct a severe vitamin D deficiency and very high doses of supplementation are often recommended for a couple of months and then maintenance doses of 800-1000 international units are typically recommended thereafter, although somewhat higher doses are also thought to be safe. Vitamin D has been postulated as a risk factor for getting Covid infections and also having more serious infections, but this is still a topic of some debate. Given the current scientific evidence, it’s not unreasonable to consider vitamin D supplementation for general health reasons.
I read that for the Moderna vaccine they ask the following questions prior to you getting the shot. 1. are you on blood thinners 2. are you a bleeder. I would answer yes to both. Is there a concern here and if so would it apply to all the Covid vaccines? Yes, these questions are asked prior to vaccination, but either being on blood thinners or having a history of bleeding are not contraindications to getting a vaccination–these are just things that alert the people giving the vaccine to be on the alert for bleeding.
I received the first Moderna vaccine and had a sore arm for a couple of days. Eight days later, the injection site was puffy, red and itchy, in an area about 1.5 by 2.5 inches. It lasted two days. Is it common to have a delayed reaction? Everything I’ve read about side effects only refers to the first few days and the v-safe emails from the CDC stopped after a week. This is a somewhat unusual reaction, but the injections are designed to trigger an immune response which certainly can be local in the injection site. Some people even get swelling in their axilla (or armpit) which is thought to be due to a local lymph node reaction to the vaccination. For anyone who has an unexpected reaction to the vaccine, I recommend checking with your health care provider. And you’re right that most side effects occur in the first couple of days but unusual reactions can occur.
I am due to get the 2nd shingles shot in mid January. Is it ok to get the virus shot as soon as I can. I am 76 years old. You should check with your health care provider about how you want to schedule these two vaccines, whether they want you to postpone the shingles vaccine and have you get your Covid vaccine first, etc.
Here are the CDC guidelines that address your question: “Wait at least 14 days before getting any other vaccine, including a flu or shingles vaccine, if you get your COVID-19 vaccine first,. And if you get another vaccine first, wait at least 14 days before getting your COVID-19 vaccine.
If a COVID-19 vaccine is inadvertently given within 14 days of another vaccine, you do not need to restart the COVID-19 vaccine series; you should still complete the series on schedule. When more data are available on the safety and effectiveness of COVID-19 vaccines administered simultaneously with other vaccines, CDC may update this recommendation.”
Please be safe.
For a full, archived and indexed list of questions, go here.
Dr. Stephen Bickel, M.D.
Dr. Bickel, currently the medical director of the Flagler and Volusia County Health Departments, treats HIV and Hepatitis C patients at both departments, treats internal medicine patients at the Volusia Volunteers in Medicine free clinic, and is the medical consultant to the Community Care program at 9 Advent Health campuses in Florida.Dr. Bickel has a BA from Brown University, an MD from Rush Medical College, as well as MBA and MPH degrees from UCLA. He did residency training in internal medicine at Rush, public health/preventive medicine residency training at UCLA, as well as an endocrinology research fellowship at the University of Chicago. He is board certified in internal medicine and preventive medicine, as well as being a credentialed HIV specialist and a certified hypertension clinician.
He is very interested in how the social determinants of health impact our community and how we can address health disparities by improving our safety net. He has been on the Board of Directors of Flagler Cares since its inception.
Disclaimer: The content in FlaglerLive’s “Ask the Doctor” column is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website. If you think you may have a medical emergency, call your doctor, go to the emergency department, or call 911 immediately. Reliance on any medical information provided by FlaglerLive.com or medical professionals presenting content for publication is solely at your own risk.