Like many Americans, Linda Snider, 49, a radiologist in Omaha, NE, has been taking every precaution to avoid contracting COVID-19. She and her husband have both been able to work from home, they've limited their time in public places, and they haven't invited anyone over. The isolation has been tough, Snider says, but necessary.
She's especially vulnerable because she has spinocerebellar ataxia type 1, a rare movement disorder that has weakened her throat muscles, so the coughing COVID-19 causes could be dangerous. “I've worried that if I got the virus, I would be at a very high risk of having complications, being hospitalized, and even dying from it,” she says.
“It's felt like an endless cycle of having to be careful about every little thing and changing my entire life,” Snider says. “I'm a really social person, and it was hard for me to suddenly have to stop seeing people.”
When Snider first heard that a vaccine would be available before the end of 2020, she had her doubts. She wondered how it could be safe or effective when vaccines typically take years to make. But her skepticism dissipated after she read vaccine-related emails from the hospital where she works, watched webinars from the US Centers for Disease Control and Prevention (CDC), and followed information from her local health department. “Reviewing all the data helped change my mind,” she says.
Snider signed up immediately when the hospital began offering COVID-19 vaccines to employees, and she received the Pfizer vaccine, in two doses three weeks apart, in December and January. She had some side effects, including arm pain after the first shot and chills and body aches after the second. But she finally feels a glimmer of hope about life getting back to normal.
Snider's early skepticism toward the COVID-19 vaccines is shared by many Americans. To address that hesitancy and allay people's fears, we asked infectious disease specialists how the vaccines work and how to get immunized.
The COVID-19 vaccines were produced with unprecedented speed, thanks in part to scientific advancements achieved through years of research on vaccines. The federal government has spent upwards of $12 billion to get effective COVID-19 vaccines created as quickly as possible. In addition, pharmaceutical companies began mass producing the vaccines before they received authorization so they could distribute them as soon as they were authorized to do so.
To date, three vaccines—Pfizer-BioNTech, Moderna, and Johnson & Johnson—have become available in the United States. The US Food and Drug Administration (FDA) granted all three Emergency Use Authorization, which can be applied during public health crises to vaccines and medical procedures even if the manufacturers haven't been granted licenses. The authorization was based on data from clinical trials in which tens of thousands of people received the vaccines and half were tracked for two months after they received their final doses. In the trials, which are ongoing, the Moderna and Pfizer vaccines were found to be 94 to 95 percent effective. Both the Moderna and Pfizer vaccines require two doses, generally given three to four weeks apart. The Johnson & Johnson vaccine is a single shot, doesn't require special low-temperature storage like the other two vaccines, and was found to be 85 percent effective against severe disease.
How the Vaccines Work
Vaccines are designed to teach the immune system to recognize and destroy a virus before it takes over the cells' genetic machine, multiplies, and does damage. The Pfizer and Moderna vaccines use a different approach from most traditional vaccines: Instead of a weakened or inactivated version of a virus, the COVID-19 vaccines use messenger ribonucleic acid (mRNA) from the virus, which triggers cells to make only the protein that looks like the spike protein on SARS-CoV-2, the virus that causes COVID-19 (and is studded with proteins that help it enter human cells). By making only the protein and no other part of the virus, the body recognizes the unarmed virus as an invader and builds an immune response, making antibodies in a process similar to what happens when a person is infected with COVID-19. It subsequently produces that same response if it comes into contact with the actual coronavirus.
Although this technology hadn't been approved for use in humans before, scientists have studied it for decades, says Maria Elena Bottazzi, PhD, co-director of the Texas Children's Hospital Center for Vaccine Development at Baylor College of Medicine. She and her colleagues are exploring an approach that may be used for another COVID-19 vaccine.
“We've been working on similar coronavirus vaccines for at least 10 years,” Dr. Bottazzi says. “We didn't complete the process earlier because there was little funding and no sense of urgency at that time.”
The presence of the new coronavirus in so many people made it possible for clinical trials to move quickly and compare disease rates in people who were vaccinated with disease rates in those who weren't. If there isn't enough virus circulating in the population, it can take years to do those kinds of comparisons, says Dr. Bottazzi.
Safety Ensured
As for suggestions that the mRNA vaccines can alter a person's DNA, Dr. Bottazzi says it's impossible. “The mRNA vaccines give the body a code that can go only one way,” she says. “The mRNA is read by cells, which make it into a protein.” The mRNA can't enter the part of the cell that contains DNA, she explains.
The main ingredient of both the Moderna and the Pfizer vaccines—mRNA that is encapsulated in a lipid, a type of fat—is safe and has been thoroughly tested in the preauthorization clinical trials of the vaccines and the period now involving millions of people being vaccinated, say Kenneth L. Tyler, MD, FAAN, chair of neurology at the University of Colorado School of Medicine.
The Johnson & Johnson vaccine uses an adenovirus—an engineered version of a virus that causes the common cold—to carry DNA that instructs cells to make proteins that resemble a part of the new coronavirus. The body then produces antibodies to attack the virus. The adenovirus is safe in humans and doesn't replicate; this same technology was used to make an Ebola vaccine that has been approved by the European Commission, according to Johnson & Johnson.
No COVID-19 vaccines—whether authorized by the FDA or in development—contain any component of the virus, which means they cannot give anyone COVID-19. What they can do is reduce the chances that people will develop COVID-19, says Philip De Jager, MD, PhD, professor of neurology at the Columbia University Vagelos College of Physicians and Surgeons. “If you are vaccinated and encounter the virus, you may still get infected, but you are likely to have no symptoms or a very mild case. The vaccine gives the immune system a running start in combating the virus if it enters the body,” he says.
People who already had COVID-19 should still get vaccinated, according to recommendations from the CDC. After having COVID-19, people are protected for about three months, says Maria Nagel, MD, professor of neurology at the University of Colorado School of Medicine. The vaccines may offer longer protection, but how long won't be clear until there are more data from clinical trials, she says.
How to Get Vaccinated
So far, more than 60 million Americans have received at least one dose, according to the CDC. Each state sets its own policies for who is eligible to get the vaccine. In most states, health care workers and residents of long-term care facilities had priority. Older adults and essential workers such as teachers and grocery store workers were also near the front of the line in many states. Some states have expanded eligibility to people with certain health conditions. In some states, including Maine, New York, North Dakota, and Washington, people with neurologic conditions qualify for a vaccine. In mid-March, President Biden announced that all adults will be eligible to receive a vaccine by May 1, and he has directed states to make it happen.
Every state has a different system for making appointments—through a website, over the telephone, or in person—but they've often been hard to come by. However, for Nancy Law, a 70-year-old with myasthenia gravis who had COVID-19 in November, it was easy. Due to her participation in an ongoing clinical trial related to her disease at the University of Colorado, Law was able to get an appointment through the university hospital network's website. On January 30, she went to a drive-through site in the parking lot of a baseball stadium, where thousands of people were scheduled to get vaccines.
The whole process took about 30 minutes, including 15 minutes after the shot when vaccine recipients were monitored for any reactions. “I was so sure there'd be a long wait that I took a water bottle, a snack, and an iPad. Before I could take a sip of water, I was in the post-vaccine waiting area,” says Law, who lives in Parker, CO, and is chair of the board for the Myasthenia Gravis Foundation of America. She got her second dose in February.
People should talk to their doctors or check with their states' vaccine websites for information on getting appointments. Online resources include the AARP, NBC News, and Boston Children's Hospital's nationwide VaccineFinder.
Side Effects Information
After getting the vaccine, people may experience pain and swelling in the arm where the shot was administered; develop a fever, chills, or a headache; or feel more tired than usual. These reactions indicate the immune system is responding to the vaccine, not that the person is experiencing COVID-19. Side effects are more common after the second shot, according to the CDC. If side effects don't resolve after a few days, the CDC recommends that people contact their health care providers. (They also can log their reactions with the Vaccine Adverse Event Reporting System—run by the CDC and other government agencies—at vaers.hhs.gov.)
After Taylor Sterk, 33, an Atlanta data analyst who has essential tremor, got his first dose of the Pfizer vaccine (through his job with Emory Healthcare), he had a headache for a day. After the second dose, he felt like he'd been hit by a hurricane. “I had a terrible headache, lost my sense of taste, and got cold, clammy hands. My back ached, and I got about two hours of sleep that night,” he says. But by the third day, Sterk felt like himself again.
It remains unclear why people have different reactions to the vaccines, but it could be related to age, weight, an underlying health condition, or the state of one's immune system, says Dr. Nagel. Researchers have yet to study why some people have side effects after the COVID-19 vaccines and others don't, she says.
Minimizing a Bad Reaction
Drinking fluids, resting, and taking acetaminophen (Tylenol) can help with post-vaccination side effects, says Richard J. Nowak, MD, assistant professor of neurology at the Yale School of Medicine and director of the Yale Myasthenia Gravis Clinic.
“The body is mounting an appropriate immune response to the vaccine,” he explains. In people who take immunosuppressant drugs, the vaccine may not be as protective, Dr. Nowak says, so he recommends that patients contact their neurologists before getting the vaccine to see if their medications should be adjusted or if they need to time their vaccinations differently.
Still, everybody should get vaccinated, advises Joseph R. Berger, MD, FAAN, professor of neurology at the Hospital of the University of Pennsylvania. “Right now our concerns are theoretical. The disease is real. To the best of our knowledge, regardless of what the patient is taking, the vaccine is going to have some degree of efficacy. Even if it is 70 or 80 percent, it is still protective,” he says.
Reports of people having a severe allergic reaction known as anaphylaxis after getting a COVID-19 vaccine shot prompted the CDC to recommend that everyone be monitored for 15 minutes afterward. People with a history of severe allergies should be monitored for 30 minutes.
To contribute to the CDC's understanding of the vaccines and their side effects, people can register for a smartphone app, which asks about post-vaccination side effects and sends reminders about second doses. The CDC analyzes the data to learn how people are tolerating the vaccines. The body can take a week or two to generate a full immune response, according to the CDC.
Underlying Conditions
There is no evidence that COVID-19 vaccines can worsen neurologic disorders, says Richard A. Lewis, MD, director of the neuromuscular clinic at Cedars-Sinai Medical Center in Los Angeles. Initially, health officials thought people with Guillain-Barré syndrome (GBS) should not get the vaccine, but the CDC has confirmed that it is safe for them. Citing data from the Moderna and Pfizer clinical trials, the CDC says no cases were reported of people developing GBS after being vaccinated.
“The overwhelming recommendation,” says Dr. Lewis, “is that you are much safer getting the vaccine than not getting it.”
The vaccine is essential for people with neuromuscular diseases such as myasthenia gravis and Parkinson's, says Dr. Tyler, because COVID-19 can cause breathing difficulties. It's also important for those with conditions that affect memory or cognition, such as Alzheimer's disease, he adds. “Many patients with dementia or impaired cognition may find it difficult to follow measures such as wearing masks, social distancing, and handwashing that reduce the spread of COVID,” he says.
Even as more and more people are being vaccinated, myths about the vaccines abound—including that they cause infertility or were developed to track people with microchips. To counter these falsehoods, Erin M. Feinstein, DO, assistant professor of neurology at Rutgers New Jersey Medical School, directs her patients to the CDC website. She also points out that COVID-19 can exacerbate neurologic conditions. In her practice, patients with essential tremor who became infected with the virus experienced more severe tremors that were less responsive to treatment, even months after recovering from COVID-19. By contrast, she says, there are no data that the vaccines cause tremor, memory problems, breathing difficulty, or stroke. “But there are clear data showing COVID-19 causing all these things and other neurologic complications.”
Back to Normal
Until at least 70 percent of Americans are immune to COVID-19 through either vaccination or exposure to the virus, everyone should continue to wear masks, social distance, and wash hands often, Dr. Tyler says. It's still unclear how well the vaccines protect against new coronavirus strains thought to be more infectious, like those first identified in Brazil, South Africa, Britain, and most recently in California and New York. Experts agree, however, that the variants have made it even more urgent that as many people get vaccinated as possible. And more data are needed for us to know whether people who are vaccinated can transmit the virus.
What is certain is that vaccines are putting us on a path toward a more social life, Dr. Bottazzi says. “Eventually I'll be able to travel, meet people in person, and visit my family, knowing that we have all been vaccinated and are protected. The hope is that once everyone is vaccinated, any remaining virus can be rapidly detected and contained,” she says.
As for Linda Snider, she's now more comfortable going out in public while wearing a mask. First on her post-vaccination list was getting her hair cut. Next was going into work a couple of times a week to be with co-workers who have all been vaccinated. “I actually hugged a physician I work with. It had been so long!”
Overcoming Vaccine Hesitancy
The vast majority of Americans—71 percent, according to one survey—say they would definitely or probably get a vaccine for COVID-19, but not everyone is jumping at the chance. In a December 2020 poll conducted by the Kaiser Family Foundation, 27 percent of respondents said they probably or definitely would not get the vaccine, even if scientists say it's safe. Some groups show more reluctance than others, including Republicans (42 percent), those between ages 30 and 49 (36 percent), rural residents (35 percent), and Black adults (35 percent).
“Some of my patients are concerned about how quickly the vaccines were developed,” says Roy Hamilton, MD, MS, FAAN, associate professor in the departments of neurology and of physical medicine and rehabilitation at the University of Pennsylvania. “Other patients have said they want to wait until after the first wave of people have been vaccinated.” There are also people who don't trust government-related immunization efforts. To reduce these fears, doctors and other public health workers have been addressing people's hesitancy.
“It's not unreasonable that getting vaccinated would be distressing,” says Dr. Hamilton. “It's important not to be derisive or dismissive of another person's point of view.” Instead, he explains to patients why he's getting vaccinated—because getting sick from COVID-19 is too much to risk—and cites evidence that convinced him the vaccines are safe and have been thoroughly tested. He tells patients, “The vaccine is a meaningful way for me to protect myself and the people I love.”
Those who are skeptical of the speedy vaccine development, or don't trust health systems or governments in general, should talk to their doctors or health care providers, says Kasisomayajula Viswanath, PhD, endowed professor of health communication at the Harvard T.H. Chan School of Public Health. Or reach out to trusted local organizations, such as churches and community groups, for vaccine information.
Some people are concerned that the development process was politicized and biased, says Rupali J. Limaye, PhD, director of behavioral and implementation science at the International Vaccine Access Center of the Johns Hopkins Bloomberg School of Public Health. She emphasizes that the pharmaceutical companies followed standard procedures to show safety and efficacy.
Dr. Hamilton, who is Black, says getting vaccinated is vital for African Americans since they have been disproportionately affected by the virus. But he understands why many are reluctant. “Patients of color, and Black patients in particular, have a long history of mistreatment at the hands of the medical profession, including unsolicited medical experimentation and discriminatory care,” he notes.
It's helpful for all to share concerns and listen to others. “People should feel comfortable having these discussions,” says Dr. Hamilton. “And they should be framed as conversations, not as arguments.”
