Boost Your Immunity
Greetings from the back of the car! There’s nothing like a 16-hour drive home from spring break in Florida to bang out some deep thoughts about COVID, risk management, and acceptance of things that are out of our control (like I-95 Northbound).
So let’s dig in!
Last week the FDA authorized a fourth shot—a second booster—for a wide swath of the population, naturally sparking confusion and loads of questions from my patients and readers.
The broad nature of the FDA’s announcement signals our federal government further shifting the responsibility of protecting against COVID to the individual (for better or worse). Indeed, the absence of more specific guidance within their announcement is akin to an open salad bar of vaccines.
As you know, I’m a huge fan of the COVID vaccines. They continue to do an extraordinary job of taking the claws and fangs away from the virus, turning it into a more manageable respiratory illness. That said, creating a veritable buffet of choose-your-own vaccine dosing is both good and bad.
It’s good that many people who actually need a second booster now have access to one.
It’s bad that 80 million Americans don’t have access to a primary care provider with whom they can make these kinds of nuanced decisions.
I actually testified in front of congress again last week about these very issues—specifically the importance of trust, nuanced guidance, and access to a primary care medical home—particularly in a global health crisis! My opening statement is here, my written testimony is here, and the whole hearing is here if you are interested.
So what exactly did the FDA announce?
They granted access to a second booster shot of either the Pfizer-BioNTech or the Moderna vaccine, four months after the first booster dose (of any authorized vaccine) to the following groups:
Anyone over age 50
Anyone over age 12 who is significantly immunocompromised, i.e. solid organ transplant recipients
Next, what are the data and reasoning behind these recommendations?
Well, this is where it gets interesting, so buckle your seatbelts. The FDA used two studies to justify their recommendation:
One is a badly confounded Israeli study that compared people who were boosted against people who were not boosted and looked only at a 40-day period that began 7 days after the fourth shot. It showed a marginal benefit to those who were boosted, but even Paul Offit, an advisor to the FDA and “Godfather” of vaccines, said how “deeply flawed” this study is.
The other is a much better study published by our own CDC comparing boosted with un-boosted patients in the U.S. during the Omicron surge. It looked at two endpoints: 1) the subjective need to visit an urgent care or ER due to COVID-19 and 2) the need for hospitalization due to COVID-19.
I’m not even going to talk about the data on the first endpoint (needing urgent care) because it’s quite confounded by the absence of anywhere else to go other than urgent care for way too many people in this country (see my testimony above!).
In other words, people who don’t have access to testing—or a primary care physician when they do test positive for COVID—are much more likely to end up seeking emergency care when they otherwise might be treated at home. This will skew these data. But what IS worth discussing is the data on vaccine effectiveness when it comes to hospitalization (a more objective measure of disease severity). Here is what they found:
People who got three mRNA doses had a 90% reduction in the risk for hospitalization. Let me say that in all caps and in bold: NINETY PERCENT RISK REDUCTION!
People who got one J & J and one mRNA dose had a 78% reduction in risk.
People who got two J & J shots had a 67% reduction in risk.
People who got one J & J shot had a 31% reduction in risk.
The upshot?
As of last week, most people who want to can go out and get a 4th shot.
But should you get a fourth shot?
This is where it helps to have a primary care provider. But here are my takeaways to take to your own doctor (and if that’s me, hello again!):
If you already had three mRNA shots, you can feel VERY reassured that the three-shot series continues to hold up beautifully against hospitalization and death. If you had told me back in the panicked spring of 2020 that we’d have vaccines that reduce the risk of serious illness by 90%, I wouldn’t have believed our good fortune! (Please note that a 90% risk reduction is not equivalent to saying that 10% of people who had three shots will land in the hospital—not at all! As always, these percentages are about relative—not absolute—risk, comparing a cohort of boosted people to a cohort of non-boosted people.)
If you had three mRNA shots and are immunosuppressed; frail and elderly; or have significant underlying health conditions like obesity, then I’d probably get a fourth shot, but with the clear understanding that the incremental benefit is marginal but that the downsides are probably minimal. (Again, this is where you should get advice from your own doc.)
Indeed the tiny percentage of vaccinated people who do get seriously ill from COVID-19 are the very same people who benefit most from the first three shots. It’s also worth noting that even with four, five, or six shots, the risk of infection doesn’t go away. This virus is unfortunately here forever, joining the ranks of the other four coronaviruses we’ve lived with for eons. All we can do is reduce the risk of serious outcomes by caring for our underlying health, with vaccines, and with oral antiviral medications as needed for high-risk people—and lobby our government to work on the structural problems that set people up for poor outcomes.
If you are in the other three categories above—that is, people who had J & J as their first shot—you already should have had your first mRNA booster. And if you didn’t, go get one. If you already had the mRNA booster and it’s been four months since you got it, you can consider getting a second mRNA booster now. How important it is to get that second mRNA shot entirely depends on your underlying health conditions, age, and risk tolerance—as always! Note that it doesn’t seem to matter which mRNA shot to get, though there is some preliminary evidence that “mixing and matching” vaccines (that is, getting Pfizer then Moderna or vice versa) has some slight benefit—just not enough for me to recommend shopping around to pick your brand of vaccine.
If you already had COVID-19 itself, the booster calculation is a little different. Vaccinated people who had Omicron (BA.1) this past fall or winter essentially already had a booster. In other words, by getting COVID itself, your immune system already has “seen” the real virus and, at this moment, doesn’t necessarily need any further boosting (i.e. reminding) to mount an appropriate immune response to protect against future reinfection. In fact, the evidence so far shows that a past infection with BA.1 offers strong protection against the currently circulating version of Omicron called BA.2. (For more details on BA.2, you can read my recent newsletter here.) If you had COVID-19 back in 2020 or earlier in 2021—with Alpha, Beta, or Delta—the immunity you mounted may or may not protect against Omicron, so you might consider a booster, again while considering your unique medical vulnerabilities, immune system, exposures, and risk tolerance. The complexity here is why there’s really no way the FDA or CDC—even in the best of times—could possibly speak to every person’s unique situation. It’s also why I’ll hopefully always have a job!
What is the optimal timing of a booster shot? This, to me, is the most interesting—and potentially most vexing—question, because there’s no right or wrong answer. In other words, “not today” is a perfectly acceptable answer for the vast majority of triple-vaccinated or double-vaccinated-and-COVID-recovered patients given how well they’re protected. For example, I don’t turn 50 until October and am fortunate to have a normal immune system and live with other COVID-immune people, so I’m perfectly content with my three COVID shots. Even if I were 50 already, personally I wouldn’t rush to get a second booster right now given the currently low disease prevalence where I live and given that even with four shots I could still get COVID and still transmit the virus to others when symptomatic (in which case I’d test and stay home.) But let’s imagine this fall when we may have another surge around my birthday month which likely will involve indoor gatherings (hint hint, dear hubby), I’d probably get a booster two weeks pre-party when the risk of an exposure might be higher. Make sense? The optimal timing of your booster shot is written in the stars. My advice is to not fret too much about making a perfect guess!
What’s the upshot of the upshot?
Unsurprisingly, the booster announcement has kicked up people’s anxiety and confusion—in part due to the mixed messaging from our public health institutions and in part because many people understandably confuse the availability of more booster shots with the lack of effectiveness of the primary series against COVID. Worrying about how well we are protected against COVID is a natural, expected consequence of the suggestion that anyone over 50 should be boosted—which is exactly why I wrote this ditty this weekend: Not to dismiss people’s anxiety but rather to acknowledge it; to contextualize blanket statements and sensationalist headlines around boosters; and to offer reassurance when the data supports it. As it does.
Additionally, I want to make clear how very important it is to get a fourth dose for people who haven’t had COVID, have only had three mRNA shots (or one or two J & J shots) and are seriously immunocompromised—like my solid organ transplant patients or my patients on heavy immunosuppressant medications. These are the people who would likely benefit from another shot but, even more importantly, benefit from Evusheld as prophylaxis and Paxlovid for treatment. I have called in more Paxlovid in the last week than I have since it came out! I am delighted it is more readily available—through Biden’s Test-to-Treat program with locations here—in order to help further reduce the risk of serious COVID outcomes in our most vulnerable patients.
And last, it’s crucial to manage our expectations of what the available vaccines and therapeutics can do while celebrating their benefits (as is the case with any chronic condition or in the presence of any endemic virus). There is so much we cannot control—from the ubiquitousness of COVID to other peoples’ risk and risk tolerance—and so much that we can control—from our vaccination status to caring for our underlying health—that it’s increasingly important to understand the differences.
As I said in my congressional testimony:
Being human is risky. Eliminating all risk isn’t possible. It’s the job of public health—and of primary care—to help people manage and balance the everyday risks people inevitably face.
Whether it’s managing COVID risk or boredom from the back seat, let’s do it—together.
I will see you next week. Until then, be well.