A Spring 2024 COVID Update
Booster shots, new CDC guidelines, home tests, & what’s next 🦠
ICYMI 👉
How to Find the Right Doctor (& Get the Most Out of Your Appointment)
A Surprising Fix for Weight Gain, Digestive Woes & Skeletal Pain
Have you heard enough about COVID for one lifetime? If yes, go ahead and skip this week’s ditty. (You might like my piece about Taylor Swift instead.)
But if you’re wondering about a spring booster and trying to understand the new CDC isolation guidelines, this one’s for you.
Photo credit: my iPhone, pic taken yesterday on my street. (These little buds give me hope.)
-
The current landscape
COVID has joined the ranks of our long list of seasonal respiratory viruses such as RSV, influenza virus, parainfluenza virus, etc. While COVID isn’t going away, it is causing less severe disease and far fewer hospitalizations and deaths as a result of highly effective vaccines, sophisticated therapeutics, and widespread population immunity (i.e. the combination of vaccine-induced and infection-acquired immunity in our communities).
Of course no one wants to get COVID, regardless of severity, but the good news is this: if you are vaccinated and/or COVID-recovered, and if you are in generally good health with a normal immune system, COVID is no longer the existential threat it once was. The risk is on par with other seasonal respiratory viruses we’ve contended with before.
Yet COVID still poses unique risks for elderly, frail, immunocompromised, and medically challenged people, not only due to the COVID infection itself but because any virus—COVID or otherwise—can exacerbate underlying health issues. For example, a diabetic will see an increase in their blood sugar readings while sick with a virus; a frail patient likely will lose some strength from a viral infection, and so on. These are the patients we need to protect the most, and for whom the boosters exist (see below).
A small subset of people will develop long COVID—lingering symptoms that can last weeks, months, or even years—however it’s becoming more clear that the risk of long-lasting symptoms from COVID is on par with the tail of symptoms we’ve seen following other respiratory viruses.
5 things to do when you get COVID this season
Treat your symptoms as needed. There’s nothing like hydration, rest, and chicken soup to ease symptoms of a respiratory illness. But if you are looking for treatments, I like Ibuprofen or Acetaminophen for body aches/fever, Robitussin for cough, and nasal saline plus/minus an OTC steroid nasal spray for nasal congestion as needed. Of course, you should talk with your own doctor for specifics. What about Paxlovid? Paxlovid has been shown to reduce the risk of serious COVID outcomes for unvaccinated patients. It is not as efficacious in vaccinated people. How is that? Because the vaccine already does a great job at reducing the risk of serious disease, such that lowering an already low risk isn’t always worth the hassle and side effects of the drug. That said, I do prescribe Paxlovid for my highest risk patients (e.g., organ transplant patients, patients on heavy immunosuppressants) and for anyone who wants it and is willing to tolerate the potential for side effects and rebound symptoms. Can Paxlovid reduce the risk of long COVID? Some data says yes. Thankfully long COVID is increasingly rare, and it’s clear that the vaccine helps protect against it.
Stay home when you are sick. The best way to reduce the spread of viruses like COVID is to avoid close contact with other people when you’re actively sick. How long are you contagious for? The duration and degree of contagiousness varies from person to person. Most vaccinated and/or COVID-recovered people are contagious for about 3-5 days after the first symptom onset. However, under the new CDC guidelines, people who test positive for COVID no longer need to isolate at home if they have been fever-free for at least 24 hours without the aid of medication and their overall symptoms are improving. This makes intuitive sense, insofar as the presence of a fever suggests the presence of contagious levels of virus in the body.
Consider testing. If you’re seeking more precision on when to end your isolation, consider using rapid home antigen testing (i.e., RATs) to guide you. While they are far from perfect, these tests do a good job of telling you if you have contagious levels of virus in your nose. In other words, a negative RAT can give people who need that extra confidence about their contagiousness that they are not putting others at risk.
Consider masking. If you are recovering from a virus, you are unsure if you’re contagious and/or you want to be extra cautious around other people (for example, high risk individuals with whom you live), consider wearing a well-fitting, high-grade mask around others.
Remember that recovering from COVID “naturally” boosts your immune system. Getting COVID itself provides a boost of your immune system, offering your body broader protection than even the vaccine can. When your immune cells “see” the real virus, it mounts a sophisticated response to help you recover and to create memory cells to spring into action the next time you’re exposed to the virus.
Do you need a spring booster?
The CDC recently recommended that people 65 and older should get another COVID booster shot this spring. Recall that there is only one COVID vaccine currently: the monovalent vaccine that targets the XBB.1.5 subvariant. This was the vaccine that became available in the fall of 2023.
What’s the rationale for this recommendation? The CDC published data suggesting that vaccine effectiveness against COVID-associated hospitalization drops from 52% to 42% during the first seven to 59 days after the monovalent shot.
Allow me to supply some context: these data are a mess. To be clear: I am not advocating against a spring booster for patients over 65; I’m simply pointing out that there are so many confounders in the CDC’s data that it’s nearly impossible to deduce from it that a booster shot significantly reduces hospitalization risk in those ages 65+.
First, data on COVID hospitalization numbers are still confounded, as hospitals still don’t tease out who is hospitalized due to COVID versus who is hospitalized for something else (say, an appendicitis) with an incidental (+) COVID test.
Second, the denominator here is massive and unknowable. In other words, if hospitalizations are a share of total cases, and we aren’t reporting total cases, the risk of hospitalizations per total number of cases is likely lower than is being reported.
Third, this kind of non-randomized data makes it nearly impossible to attribute the reduction in hospitalization risk to a single booster shot, as opposed to something else that people who get more shots have in common (such as past vaccine doses, a healthier lifestyle, or better access to healthcare, for example).
Last, as my friend Shira Doron, Professor of Medicine and Hospital Epidemiologist at Tufts wrote to me yesterday when I was checking my work, “My main issue with the [CDC] study is that even if there is a difference, they only went to 59 days. And we know that the prevention of infection drops precipitously by around 10 weeks. So every six month boosting is not a public health strategy. I think about Paul Offit's quote: “boosters boost.” Older people will get a little short lived boost in immunity that may prevent infection for a little while and in doing so would prevent hospitalization if they are really fragile and would be hospitalized by an otherwise mild respiratory infection.
The upshot
I am happy for my patients over 65 to get another booster shot. I will even recommend it to some. Why? Because even if the upsides of another shot are small (a transient boost in antibody levels that may or may not reduce your risk of infection, symptom severity, or risk of hospitalization, depending on the degree of your “pre-boost” risk for each), the downsides are probably small, too. For patients who’ve already been vaccinated, have had COVID, and are managing their underlying health, we are talking about tiny degrees of risk on both sides here.
But please do not think that if you’ve only had one monovalent vaccine last fall that your risk of being hospitalized is 52%. It’s not. Your risk of hospitalization due to COVID is around zero if you are young and healthy. It is close to zero if you have managed underlying health, you have been vaccinated, and you have access to a doctor to prescribe Paxlovid as needed and to monitor you as an outpatient.
Should you get a booster if you are < 65 years and have underlying health conditions? The CDC says yes. As with any medical decision, this one is nuanced and depends on many factors such as your last bout of COVID, your age and condition.
I would argue that better than a spring booster shot is BOOSTING your innate immune system. How? By prioritizing sleep, exercise, nutritious meals, and time outside in nature—all things that your immune system needs to be healthy—and by checking in with your doctor to help manage your underlying health issues. Losing 10 pounds of extra weight, cutting back the booze, and monitoring your home blood pressures more closely might have more of a meaningful impact on your next bout of COVID that another shot would. And I’ll say it again for the cheap seats, avoid close contact with people who are actively sick!
What if you recently had COVID?
The CDC recommends that people who recently had COVID should wait at least three months to get their next booster. It looks to me that waiting four to six months is optimal, since getting infected offers strong and broad protection for the next time we are exposed. Of course there is no perfect answer here, which is why it’s critical to understand the medical data and how it applies to your situation and to talk with your own doctor for nuanced advice.
What’s next?
Note that we will probably have another new round of COVID boosters in the fall. The vaccines likely will be reformulated to match the variants likely to be circulating in winter 2023. Getting a booster now should not prevent you from getting a booster in the fall.
The evolving CDC guidance seems to be settling into the following cadence: if you are at high risk for hospitalization and death from COVID, consider a booster shot every six months, and if you are at low or average risk, consider an annual booster in the fall.
Got questions? Drop me a line below!
Got friends with questions? Share this widely!
If you found this post helpful, please share it widely! Also click the ❤️ or 🔄 button below so that more people can discover it on Substack 🙏
Disclaimer: The views expressed here are entirely my own. They do not reflect those of my employer, nor are they a substitute for advice from your personal physician.
Dr. McBride,
I’m not sure I will ever trust what the cdc says ever again. From the made up rules (not based on science) during Covid. To now making statements about men breastfeeding (???). I just can’t.
No more Covid vaccines for me, we need to build our immune systems.
*just my opinion, I am not an expert
Sorry to harp on masks; they seem to be a bit of a hobbyhorse for me. A recent theory I’ve heard is that we can’t “protect others” from viral infections by wearing masks, even high quality ones. Why? Let’s say we’re sick, and exhaling viral particles. They might land on the inside surface of the mask, but they won’t stay there. As we continue exhaling over the particles, perhaps for long periods of time, they’re likely to become aerosolized, and to hang in the air just as if we hadn’t masked at all. Viruses, after all, are VERY tiny. If Covid were a bacterial infection, like strep throat, masks would have been much more useful, as those infections transmit more by close contact and respiratory droplets, and masks do an ok job of containing those (again, for short periods of time, before too much moisture accumulates). Does this make sense to you? Thank you for the wonderful article!