To answer community members’ questions about the COVID-19 pandemic and vaccinations, The Sentinel hosted a Facebook Live question-and-answer session Monday with Dr. Aalok Khole, an infectious disease physician at Cheshire Medical Center.
For those who missed it, here’s a transcript of many of the questions we asked.
Question: In what circumstances should vaccinated people wear masks? And why?
Answer: “That’s a great question. It depends on several factors. As we’ve discussed in the past, what we did one year and three months ago was different from what we are going to do now. Back then, we had said, ‘Universally mask; we’re not sure what we are dealing with.’ There were a lot of unknowns. What has changed over the past 15 to 18 months is, one, we’ve had the ability to get vaccinated, and second, we have more information about what the infection really does. I think at this point ... it has to be a tailored approach, and when I say a tailored approach, it depends on self, it depends on the people you interact with, and I think, on a larger scale, it depends on the community you’re in.
“So when I say self, it depends upon, sure, OK, I am fully vaccinated, but am I immunocompromised? So am I on any medications or am I on any therapeutics that may suppress my immune system, which may limit my ability to grant me a robust response to the vaccine and protect me against potential infection to the highest degree? That’s the first question I would ask. The second question is who are you interacting with? ...
“When you’re with several unknown people whose background immunization rates, background potential exposures, background immune status is unknown, there are just too many factors that play into this level of uncertainty, which then gets escalated about your risk of acquiring infection from them, but also the risk of you granting them an infection, potentially, if you are asymptomatic. And I think the third factor that I take into consideration ... is depending on the level of transmission of the virus in your community.
“Say for example, back in June we were at minimal levels of transmission, so the overall risk of either you acquiring infection and/or you transmitting it to others was comparatively lower, so at that point, we were like, ‘If you’re fully vaccinated, that’s fine. Even if you have an asymptomatic breakthrough infection, the likelihood of you spreading it to others is low,’ and so you could go about your life in a normal way. What’s changed since then is we’ve seen the onslaught of the delta variant, which has led to, for example, several communities across the U.S., including Cheshire County, to read substantial levels of community transmission.
“We are also seeing breakthrough infections because, [if] you allow the virus to spread, it’s going to infect the vaccinated and the unvaccinated even if the degree of activity or the degree of infection that you suffer from is different. So all that put together in the current circumstances, I would say if you are a resident of the state of New Hampshire, which is overall in a state of substantial community transmission ... I would definitely say these are the times when you mask ...”
Question: What about if you’re going into a situation where everyone is vaccinated? Is that still a pretty safe situation to not wear masks, even in the indoor settings?
Answer: “Yeah, that’s a fairly safe situation. But again ... if you’re interacting, say, with grandparents, one of whom is immunocompromised — even if they are fully vaccinated — I would say that that, in the current delta variant surge situation, that may be an instance where you might say, OK, you might just benefit from masking while you’re around each other. And the same thing with respect to when you are taking kids out because not everyone’s eligible for vaccination. So if kids are going out with you, then I would say that it’s beneficial for them to try and mask. One, to protect themselves, but to a greater degree, if they’re asymptomatic transmitters, to protect the other people you’re meeting.”
Question: Families with little kids, or families who may have someone who is immunocompromised in their household, is there something special or extra they should be doing to keep their little kids safe?
Answer: “I think nothing really extra, but all these things that we just talked about, those would be instances — that’s like the fourth factor, which comes under that community-umbrella picture, is who you’re going to be dealing with ... You don’t want to get afflicted and then bring it back home. So those are the scenarios where we say, ‘OK, it’s safer to mask’ because that way you have at least one mitigation strategy in place because vaccination as a mitigation strategy cannot be applied since your kids are not eligible.”
Question: We’ve got Labor Day coming up, there’s concerts going on, all kinds of stuff. Are there situations where you would say to take a second look, even if you’re vaccinated, before heading into these types of situations?
Answer: “That’s a great question, and we actually saw an uptick in cases after Fourth of July, probably [because of] the celebrations that went on then. Fourth of July to now Labor Day, we are in a much different situation — where we had just started seeing the effects of the delta variant, now we’re in a full-blown surge. I think the biggest protector in those sort of instances is the fact that you’re outdoors.
“So we know that rates of transmission, or the likelihood of transmission, is lesser when you’re outdoors and there’s enough adequate ventilation. But, the issue is in concerts, if the masks come down, it’s way hard to say that, ‘Please maintain 6 feet of distancing’ ... I would say OK if I’m outdoors, great. But if I know that I can’t maintain 6 feet, can I at least maintain three? You extrapolate the data from what we’ve seen in schools. If you’re saying at least 3, I would say sure, even if you’re outdoors, masking is better because that reduces your chances of acquiring and transmitting. And then I would say it’s not hard to keep a bottle of hand sanitizer on you because in these settings, there are going to be high-touch surfaces ... I think that’s adequate protection.”
Question: We keep hearing more and more about these breakthrough infections, when somebody who’s vaccinated gets COVID-19. Can you walk us through how common these infections are and, overall, how serious have they been?
Answer: “I think right off the bat I would say this, that we shouldn’t take this in the negative sense that we are seeing breakthrough infections because we’ve seen everyone being very honest about this, that nothing in medicine — and [the] COVID-19 vaccine is not an exception — nothing is 100 percent.
“Again I want to urge the listeners that when we say vaccines were never meant to be 100 percent, we’re not meaning it in a detrimental way. We are just being honest about certain lacking that comes with any therapeutic intervention. So even if they were not meant to be 100 percent, they were pretty darn good that we were seeing effectiveness as high as 94 and 95 percent.
“Even with the delta variant coming in, it maybe dipped to 84 and 85, but it was still protective against severe disease and hospitalizations and death ... As the virus surges, and you see way more cases and you have a significant extent — like, for example, across the U.S., you have about  percent of your population fully vaccinated — you are going to see increasing numbers of breakthrough infections. That is not a surprise and that does not concern us to the extent that the infections in unvaccinated do. The reason I say that is ... the current surge of infections is not being caused by breakthrough infections. The current surge is driven by delta variant-related infections in the unvaccinated. The breakthrough infections are a small proportion.
“What I can definitely tell you [is] that amongst hospitalized individuals, or amongst the deaths unfortunately that result from COVID-19, the portion of unvaccinated individuals are higher, [and] vaccinated individuals are way lower ... which I think is a big, big advantage of getting vaccinated, that even if you were to have a breakthrough infection, the likelihood is it’s going to be mild, you’re going to recover, you’re not going to end up being hospitalized, and fortunately, you’re not going to be one amongst the deaths.”
Question: We’ve heard people say they got COVID-19 and were fine, so they’re now immune and won’t be getting vaccinated. Is there any merit to that argument?
Answer: “At least part of what the CDC regulations are right now, is if you’ve been diagnosed and recovered from COVID-19 in the absence of vaccinations, you are somewhat protected from reinfection, but the cap for that is about 90 days. Now I will say that there [have] been different papers published subsequently ... where they looked at folks who’ve been vaccinated with two doses and individuals who’ve gotten the infection and got vaccinated with one dose, and they compared antibody titers (levels), and they said the response is probably similar. But there are enough studies that have shown before that that immunity obtained through vaccination is more robust, more long-lasting, compared to immunity granted by natural infection, which is why the push for infected individuals to still get vaccinated post recovery ...”
Question: You’ve mentioned a few times that delta has started to spread pretty rapidly not only in our state, but nationwide. Can you talk about what leads to the development of these variants?
Answer: “Viruses, just as a part of their nature, while they’re replicating, innately there are some protein combinations that go wrong. So mutations occur by error. Now some of these mutations have no role to play, and they fall off as the evolution process continues. Some are stable, which means they’re present but they’re really not doing much. And some of these mutations — which are actually better in protein manufacturing — at times gives the virus an added ability to increase its infectivity, increase its transmissibility and potentially an ability to evade immune response. Delta is one of them ... We have yet to see a variant which is completely evading vaccine response, which is reassuring.
“What I can tell you [is] that the more you allow the virus to circulate, the more you give it a chance to develop mutations, the more you give it a chance to develop variants, and we’ll just have to wait and see. Hopefully it doesn’t happen that we end up with a variant that’s completely evading an immune response ... That is why there is a major push to get vaccinated because the earlier we curb this chain of transmission and you make the virus an endemic entity rather than a pandemic, you’re going to try and minimize the emergence of these variants and, essentially, make it easier for us to get back to normal.”
Question: Based on the opinion you expressed about taking precautions to protect children, should schools be requiring masks, at least at the elementary level where none of the children are eligible for vaccination?
Answer: “That’s a great question, and that’s been a major topic of debate across several circles. So if you look at the CDC guidance and the guidance put out by the American Academy of [Pediatrics], they did support universal masking irrespective of vaccination status in schools because the eventual game is to bring back everyone to in-person learning and not hamper their ability to grow and prosper. I think the approach that’s being taken in New Hampshire is sort of in between the two extremes.
“So the first extreme would be oh yeah, sure, no one masks, everything’s all right and keep going on. I don’t think that’s rational, and I think that’s laden with risks, which we really don’t want to take. I think the grid that [the] New Hampshire Department of Health and Human Services has come up with makes sense. So you look at what’s the community transmission levels? So when we’re at substantial community transmission levels, and you have kids going back into school, especially the elementary-age group where they’re not eligible for vaccination as of yet, it might make more sense that you make those individuals mask as an added mitigation strategy, coupled with the distancing ...
“Now if the community transmission levels were to dip, and they were to go into minimal or moderate, than you could say, sure, fully vaccinated individuals may not need to mask, while those who are not vaccinated should continue doing so, and so the same would apply to staff. But I think at this point, I would say that with the levels of transmission that we’re seeing, I think it’s safer to be masked ... if we want to prevent complications.”
Question: If a school district decides they are going to let masks be optional, and, say, only a few students decide they’re going to mask, and the rest of the students decide not to, how safe is that child actually going to be?
Answer: “That’s a good question, which is why I think it’s important to take into consideration what is going on outside. I can understand that we want to keep it optional so that everyone has the ability to make the decisions for themselves, but at times — and also, looking at it from a flip side — when the onus is on oneself, there’s always the risk of introducing subjective interpretation and bias. And those two things worry me as an infectious disease provider because when you keep it open, each one is allowed to make the decision for themselves, which at times can have consequences that are unintended.
“Looking at the way the trajectory is going in the state, I would say that approach might be a little risky, because if you’re not mandating it and you’re leaving it optional, there’s always the chance that you’re gonna have some folks that want to be safe and then the others who may be vaccinated or may not be vaccinated may not want to mask. Once again in this pandemic, it comes down to we’ve got to think of others and the community, along with yourself. This is not the time to be selfish and say, ‘Oh I’m protected, I’m fine,’ but if others are not, that’s putting them at risk for no fault of theirs.
“So I want parents and students and staff, everyone, to consider this very closely because we’re 18 months into this, there’s a chance that a lot of these things may not end up being mandated, where the onus is on oneself to take the right steps ... Let’s do the right thing. Let’s not put someone else at risk for one’s own comfort.”
Question: We’ve heard for a while now that the best thing that we can do to combat this pandemic is getting as many people vaccinated as we can. And as much as we know that, we also know that there are certain people who just aren’t budging when it comes to getting vaccinated. How can health officials convince them to get vaccinated?
Answer: “ ... I think we’ve tried several different ways in which we can convince people that this is safe, it’s the right thing to do, and we need to get vaccinated as many as fast as possible if we really want to steer clear of this issue. I can tell you that ... there are usually three kinds of subsets. There’s one that are surely geared enough that they definitely are going to get vaccinated. You have the other end of the spectrum who are not ready to get vaccinated for whatever the reason might be ... And then you have the in-betweens, who are on the fence, who are either waiting for more information or are seeking more answers to some of their questions, and are on the fence which direction they want to go.
“I think the target, right off the bat, has been those on-the-fence individuals because that’s the population that you can, if egged on in the right direction, convince them to get vaccinated ... At this point, the resources are out there, the data is out there. We know it’s safe, and we know it works ...”
Question: When will the vaccines be eligible for children under the age of 12?
Answer: “What we’re hearing now is probably by late summer, early fall, we should have enough data to at least get these under emergency-use authorization. There was also discussion that they may choose to look at that data in conjunction with the already existing data that would enable us to grant these vaccines full authorization instead of that interim step of an emergency use, so meaning when the vaccines get full authorization for adults and from ages 12 to 15 ... they might look at the data for 6 to 11 years at the same time and may expedite the process for full approval, especially if the extrapolated data shows that it’s just as safe and effective ...”
The full Facebook Live video and additional information about COVID-19 are available at: www.sentinelsource.com/news/coronavirus/