Dispel Medical Myth #2: Everyone Needs the New Booster
It’s week two of medical myth-busting! Last week I wrote about psychotherapy. This week is about booster shots. The gist? More is not always more.
The COVID vaccines are a modern miracle. Last week the FDA and CDC authorized a new COVID booster shot aimed at the BA.4 and BA.5 Omicron subvariants. These are called “bivalent” vaccines because they contain both the original vaccine formula and the new formula targeting the current circulating Omicron strains.
This sounds like a great thing, right? In many ways, yes! So everyone should run out and get the new shot, right? Not so fast.
Before we run to get boosted, it’s important to understand the why and to manage our expectations for what a booster shot can and cannot do for us. (The book I’d love to write some day is gonna be called, Just Because We Can, Doesn’t Mean We Should.)
Let’s dig in.
Who exactly is eligible for the new shots?
At least two months after any brand of vaccine:
Anyone over age 12 can get Pfizer.
Anyone over age 18 can get Moderna.
What was wrong with the old shots?
Not a whole lot. The original vaccine series (including J&J plus mRNA boosters as needed) continue to hold up beautifully against hospitalization and death.
In the Omicron era, however, the original vaccines do not do a great job against any symptomatic infection. They also don’t efficiently prevent transmission to other people.
So when you hear about “waning immunity,” this does not mean that you’re unprotected despite vaccination with the old series, even if your last shot was in 2021. What wanes over time is not protection against serious COVID outcomes, but rather the protection against infection. This is due to two phenomena: 1) Our blood antibody levels naturally decline over time and 2) the Omicron variant is different enough from the original variant such that it has outsmarted the vaccine-induced antibodies targeted against it. What Omicron has not outsmarted is our cellular immunity (T cells and memory B cells), the less measurable but marvelously muscular arm of the immune system that protects us from serious COVID outcomes.
The bottom line: You can rest assured that your original vaccine series is still working for you where it counts the most!
So what can the new shots do that the old shots can’t?
The new booster is designed to help reduce the risk of any symptomatic infection — essentially making up for the original shot’s waning protection there. The new shots trigger the production of a fresh batch of antibodies, aimed directly at the current variants. Reducing infection risk should also reduce the risk of transmission to others. (Recall that you have to be infected to give the virus to someone else.)
This sounds good, particularly as we move indoors this fall and co-mingle in crowded, poorly ventilated spaces where respiratory viruses like SARS-CoV-2 and influenza love to party.
What about people who already had Omicron?
Here’s the deal: If you had COVID during or after December 2021, you had Omicron. The immunity from past infection is strong against severe illness from a re-infection — and even better against infection compared to the vaccine. When our bodies “see” the actual virus, our immune system generates a broad array of antibodies including the kind that line our nose and upper airways (the entry point of the virus). This is something that a shot into a muscle simply cannot do.
While it’s possible to get Omicon twice, an infection with one Omicron subvariant has been shown to reduce the risk of infection with other Omicron subvariants.
The upshot: I’m less inclined to recommend the new booster to people who had the primary vaccine series plus an immunity “boost” from an Omicron infection, especially if they had COVID this summer. (See below for more.)
What about if you had COVID back in 2020?
Let’s take my husband as an example. He had COVID in November 2020, well before Delta and Omicron arrived on the scene. (Remember when the kids and I forgot to feed him in the basement? Oops.)
The combination of his 2020 infection and his two 2021 vaccine doses should prevent serious COVID outcomes should he get reinfected with the variant du jour. How? His memory B cells would kick into gear and make fresh batches of antibodies against Omicron even though his infection and vaccine were from the ancestral strain. That’s how cool (and durable) our cellular immunity is. It’s also why we cannot conflate “waning immunity” with “I’m naked in the face of this virus despite vaccination and/or past COVID infection.”
That said, my husband is theoretically at higher risk for non-severe infection because: 1) his 2020 antibodies have likely waned and 2) his 2020 antibodies were directed at the original variant, not Omicron.
The upshot: I recommend that he get the new booster shot — not because he’s at high risk for serious outcomes (his past infection and the original vaccine series have him covered) — but to help prevent infection.
How long would protection from the new booster last?
New, Omicron-specific antibodies probably will last 3-6 months, theoretically reducing the duration and severity of illness from Omicron. These new antibodies might also render the recipient less contagious if infected. At least that’s what makes sense. We don’t have human data to show this, but it would be surprising if this wasn’t the case given what we know about human immunology and the existing COVID vaccines, with 12 billion doses having been given to human beings around the world.
So … should you get the new shot?
It depends on who you ask. The CDC says get a booster if it’s been two months since your last shot. Professor Shane Crotty (someone I trust a lot) recommends a booster shot if it’s been six months since your last COVID shot or your last bout of COVID. Vaccine expert and FDA advisor Paul Offit is appropriately hesitant about the need to boost young, healthy people given the absence of clear benefits.
Here are my two cents:
I recommend the new booster to my patients who are:
65+ years old who haven’t had COVID since December 2021 and whose last boost was over 3 months ago.
50+ years old with underlying health conditions like diabetes, obesity, heart disease, etc and who haven’t had COVID since December 2021 and whose least boost was over 3 months ago.
Anyone with underlying health conditions that put them at higher risk and who hasn’t had COVID or a boost in the last 3+ months.
Anyone who is immunocompromised (though many of these patients should also be on twice yearly monoclonal antibodies i.e. Evusheld for prophylaxis.)
I suggest consideration of the new booster to my patients who are:
65+ years old whose bout of COVID and/or last booster was over 3 months ago.
50+ with underlying health conditions whose bout of COVID and/or last booster was over 3 months ago.
Younger/healthier patients without any documented history of COVID and who are eager for a top-up on their antibody levels as long as their last booster dose was over 3 months ago.
I discourage the new booster to my patients who are:
Young, healthy, vaccinated and Omicron-recovered males given the rare but real risk of vaccine induced myocarditis and the near-zero benefit of an added booster.
I will not discourage other healthy, vaccinated, and COVID-recovered patients from getting the new booster who wants one, but I will try to help them manage their expectations for what another shot can and cannot do.
Not sure if you fit into any of the above groups? Like, you’re 45 years old, four-times vaccinated, haven’t had COVID but are worried about the upcoming winter? Or you’re 70 years old, healthy and fit, had four vaccine doses and COVID in January 2022? Getting another booster is probably fine! (I did a Q & A about the new boosters on Instagram last week — see “highlights.” I will do another one this week so find me on the ‘Gram!)
What about kids? I expect the shot to be approved for younger kids later this fall. I don’t see young children as patients, but I can’t imagine recommending the new booster shot to kids who’ve had COVID already, especially if they’ve been vaccinated. Why? Because their risk for serious COVID outcomes is near zero, therefore you’d have to practically guarantee an even-closer-to-zero vaccine risk to justify more shots.
As always, it’s best to talk with your own doctor. These decisions are nuanced. Weighing risks and benefits of medical interventions is what we do!
When is the best time to get the booster?
If you’ve decided to get it, I’d wait three months (not two) since your last COVID infection or vaccine dose. Why? Because fresh antibodies can actually mute your recently boosted immunity!
If you want to get fancy, you might decide to time your booster to coincide with a predicted heavy exposure. It takes 2-4 weeks for the new booster to take full effect. The fresh antibodies should last (in most people) for 3-6 months.
Can I get the flu shot and COVID shot at the same time?
YES!!! I highly recommend the flu shot — ideally in early-to-mid October, but there’s really no bad time to get it.
Will I myself get the new booster?
Yes. I turn 50 next month. I’ve had three vaccine doses. (Four doses isn’t necessary for people like me). I haven’t had COVID yet. I’m at very low risk for serious COVID outcomes, but I’m at higher risk for infection compared to someone my age who already had COVID, even if they had it in 2020. So I’d like to have a 3 to 6 month boost of Omicron-specific antibodies to help reduce that risk — plus to reduce the risk of transmission. I don’t mind feeling “bleh” for a day or two after the shot, and my risk for vaccine-induced myocarditis is low.
Will I be bulletproof after the new shot?
Hardly! Even with 4, 6, or 10 vaccine doses, infection is still possible. As I’ve tried to explain, there is a point of diminishing returns on COVID vaccine doses for each one of us. That point for you depends largely on your age, immune status, underlying health conditions, degree of exposures, and past COVID infection.
The bottom line.
This virus is not going away. It has joined the ranks of the other four coronaviruses (the common cold viruses) that we’ve lived with for ages. All we can do is reduce the risk of serious outcomes by getting vaccinated with the primary series; try to further reduce the risk of infection with a new booster (or infection-acquired immunity); care for our underlying health; wear a well-fitted, high-grade mask only if we want or need to in crowded, indoor spaces; and be mindful of the myriad other health risks we face every day.
From social isolation and anxiety to breast and colon cancer, being human is risky. It’s the perfect time to check in with your body and mind.
Speaking of which, I’m thrilled to host palliative care specialist and gifted writer, Dr. Sunita Puri, to this week’s podcast … see below!
Sunita has spent countless hours counseling terminally-ill patients and their family members on end-of-life decisions. She describes the intersection of her family’s spirituality and her medical career in her gorgeous 2019 memoir, “That Good Night: Life and Medicine in the Eleventh Hour”.
In this week’s episode of Beyond the Prescription, she and I discuss the importance of helping people improve quality — not just quantity — of life.
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.
Please be sure to rate and review the pod — and please share it with friends!
I will see you next week. Until then, be well.