You might notice the new title of this newsletter.
“Are You Okay?” is the question I’ve found myself asking every single one of my patients during COVID. It assumes the obvious: That none of us is okay—and that regardless of our pandemic story (or our life before COVID), we’re all struggling in some way.
Asking patients up front if they’re okay gives them permission to be human. To not be okay. After all we’ve been through, how could we be?
As BA.5 cases surge, so, too, can our emotions. Helplessness, fear, resignation, anger—all of these are valid feelings as we face another spate of uncertainty. But hope is alive and well.
Last week’s newsletter was about BA.5 and the COVID vaccine for kids. This week I’ll further unpack BA.5 and answer some of your burning FAQs, for example:
Should I get a 4th shot? Or should I wait for the new vaccine formulation in the fall?
If I had Omicron already, am I protected from BA.5?
How can I protect myself and my family from this new variant?
BA.5 has also caused us to question our sense of safety. Naturally it has reignited fear. My patients who recently recovered from Omicron are particularly peeved. My patients who’ve not yet had COVID are waiting for the other shoe to drop. While the vaccines continue to work well against serious COVID outcomes, no one is immune to the stacked stressors of this pandemic. (Hence the question “Are You Okay?”)
Let’s first address three central questions:
Is BA.5 more contagious than other Omicron subvariants? YES. So far it is clearly more transmissible (i.e. easier to catch) than prior variants—even compared to its Omicron cousins (BA.1, 2, 4, etc).
Is BA.5 causing more severe disease compared to other subvariants? So far, NO. In other words, if you were to get infected with BA.5 this summer, you likely wouldn’t be any more or less sick than if you’d had BA.2 in, say, spring 2022 or BA.1 in December, for example.
Is BA.5 resistant to the vaccines? So far, NOT for the outcomes we care most about: death and hospitalization from COVID. Data show that people who have been vaccinated and boosted (if needed) remain at very low risk for serious outcomes. However, in the Omicron era (and ever since the Delta variant appeared), the vaccines no longer protect well against (re)infection. This is the reason we are seeing loads of infections with a highly contagious variant but no major spikes in hospitalizations and deaths.
Now let’s address some practical FAQs.
Q: If BA.5 is intrinsically less virulent than past variants, why are we seeing an uptick in hospitalizations in some pockets of the country?
A: Because more infections mean more hospitalizations in vulnerable people. It doesn’t mean that BA.5 is intrinsically more dangerous.
Q: Why are so many vaccinated people getting COVID—even a second or third time?
A: Because in the era of the highly contagious Omicron variant, the vaccines are less effective against infection. And because immunity (against infection only) wanes with time.
Q: What about people who already had COVID? Are they protected against reinfection and serious illness?
A: THIS JUST IN: A study just published in the New England Journal of Medicine showed that people who had COVID even more than a year ago have better protection against symptomatic Omicron when compared to people who were one-month out from the third of their three vaccine doses. In other words, those of you who had COVID already are pretty darn well protected. And those of you who have had COVID and the vaccine series are seriously in good shape.
Q: What about boosters?
A: I strongly recommend a second booster shot to my high-risk patients and to patients over age 50 if and only if they haven’t yet had COVID. With boosters—as with the primary vaccine series—managing expectations is key: Similar to the immunity to reinfection from infection, boosters seem to offer little protection against infection. Is the protection against infection ZERO? Probably not, but it’s also not great. The protective effect of a fourth dose against infection seems to wane in about two months.
The short story: The vaccines do not provide an impenetrable force field. (They never did!) They simply take the claws and fangs away from the virus and turn it into a more manageable disease. In other words, you can get an infinite number of boosters, and you could still get COVID.
Q: What about the new vaccines coming this fall?
A: The main goal of updating the vaccines to specifically target BA.4 and BA.5 is to better protect against infection and, therefore, transmission. Recall that you have to be infected to transmit the virus to other people. So it makes sense to create a vaccine that might better prevent infection. The problem with any new COVID vaccine? The virus is changing so much that by the time we have the new formula, we’ll likely already have a new variant in our midst. But that’s okay! It’s also expected. And it isn’t a reason not to update the shots. Vaccine developers are basically trying to anticipate the shape-shifting of the virus to optimally protect individuals and society from COVID.
Q: Would getting a booster now prevent you from getting a new shot this fall?
A: No.
Q: What about nasal vaccines?
A: Nasal vaccines hold great promise because, unlike the shots into arms, they generate antibodies that line the surface of the nose—right at the virus’ entry site. Nasal vaccines would therefore reduce the risk of infection. What else can deliver this kind of nasal (aka “mucosal” immunity)? Getting COVID itself! When we get infected with the real thing (not that I recommend it), our immune system makes and deploys a full range of antibodies—in our blood and in our nose. This, my friends, is likely why people who’ve had COVID are better protected against reinfection than people who’ve only had the shot.
Q: So how can we protect ourselves from BA.5 now—and from future variants??
A: Go back to basics:
Work on our underlying health conditions (for example, obesity is a top modifiable risk factor for serious COVID outcomes which is why one of the reasons I work with patients on realistic nutrition plans, sustainable ways of getting movement, and understanding their relationship with food—more on this next week.)
Get vaccinated and boosted as needed.
Ask your doctor about Evusheld, the twice yearly injection of monoclonal antibodies used preventatively, if you are significantly immunocompromised.
Advocate for better ventilation in public spaces like schools and office buildings—and know that the outdoors is still exceedingly safe.
Wear a well-fitted, high-grade mask if and only if you want or need added protection based on your unique medical conditions and risk tolerance.
Stay home and consider calling your doctor when sick. Right now, most of my patients with COVID are doing well at home with Ibuprofen or Acetaminophen as needed for aches, fever, and sore throat; Fluticasone nasal spray for nasal congestion; hydration; rest; and time.
Call your doctor for Paxlovid if you get COVID and are unvaccinated. Recall that Paxlovid is not indicated for most vaccinated people.
Call your doctor to consider monoclonal antibodies if you have COVID and are at high risk for severe disease. (Recall that having had COVID in the past reduces that risk; see above).
Use rapid antigen tests to help guide your isolation period. Recall that home rapid antigen tests are essentially “contagiousness” tests. When positive you are contagious; when negative you are not contagious—even if you feel like crap.
Manage our expectations for what life will look like as this coronavirus becomes the 4th endemic coronavirus we regularly tussle with.
As Dr. Bob Wacher, chair of medicine at UCSF, recently Tweeted: “We need to change our thinking about the value of vax/boosting. Vax/boost remains hugely valuable in preventing a severe case that might lead to hospital/death. But its value in preventing a case of Covid, or preventing transmission, is now far less than it once was.”
In other words, I continue to strongly recommend developing immunity to this coronavirus by getting vaccinated. We must also factor in the nuances of having had COVID itself—specifically with what variant, when, and how severely the patient was infected—in the decision-making process re: boosters. This is yet another reason why you need a primary care provider to guide you.
I’ll end by recommending an excellent piece—a reality check, of sorts—by Dr. Leana Wen for The Washington Post. This quote by vaccine expert and advisor to the FDA, Dr. Paul Offit, was particularly poignant:
“We can’t keep forever masking & quarantining to prevent asymptomatic infection; we have to accept mild illness as a part of life with Covid-19."
He’s right. COVID is here in perpetuity. We cannot fully eliminate the risk; we can only mitigate it. But remember this: Accepting an unpleasant reality is not the same as giving up. This is the same lesson Katherine Kendall reminds us of in this week’s podcast: Fear is normal, but it can also take on a life of its own. Facing hardship head-on can be painful; it can also set us free.
We can protect ourselves from COVID and meet our broad human needs. When we appropriately manage our expectations and recalibrate fear, we’re better able to live, work, care-give, and love. With facts in our back pocket—and our eyes wide open—we’re back in the driver’s seat of our health.
I will see you next week. Until then, be well.
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Actor Katherine Kendall was only 23 years old when Harvey Weinstein lured her into his apartment, and then cornered and sexually traumatized her. For years she felt silenced and powerless, fearing backlash if she reported the then influential producer.
Years later in 2017, Katherine bravely came forward. She was one of the first women to publicly speak out against Weinstein in a New York Times article, sending a ripple effect that would ignite the #MeToo movement. In this episode of Beyond the Prescription, the actor details her journey of overcoming the shame of being sexually traumatized; grappling with the physical manifestations of emotional pain; and finding the courage to advocate for other survivors.
As always, my newsletter subscribers get early access to the pod every Monday night before the official Tuesday launch. Give it a listen now on Apple, Spotify, or wherever you find podcasts!