Giddy-up for Fall
It’s November! ‘Tis the season of pumpkin spice lattes, cozy gatherings around the fire-pit, and accelerated culture wars over masks, natural immunity, and pediatric vaccinations.
Nothing says autumn like a politicized pandemic! Nothing invites harmonious holiday banter like a festive mix of burnout and booze!!
If you’re anything like me, you woke up this morning with a candy corn hangover and you’re ambivalent at best about the slippery slope that begins the day after Halloween.
So let’s get through the next few months safely and sanely—together.
And before you fret about the upcoming holidays, note that there’s a lot to be hopeful about. Let’s break it down:
The state of the pandemic
In the US, the rates of COVID cases, hospitalizations, and deaths continue to fall as a result of widespread vaccination and population immunity.
Could this change? Absolutely. As temperatures drop and people migrate indoors, we’re bound to see more COVID outbreaks, especially among unvaccinated folks.
The solution to getting severely ill from COVID and to preventing a fifth wave? Get vaccinated—and boosted if eligible (see below). While the vaccines certainly aren’t perfect, they are pretty darn close. They are a Science Miracle that this doctor is grateful for every single day. The vaccines take the claws and fangs away from the coronavirus and turn COVID into a more manageable illness. The vaccines also reduce the risk of transmission thereby slashing the amount of virus circulating in our communities as more and more people take the shots.
In fact, I’m eagerly awaiting updated CDC guidance on a shorter duration of isolation for vaccinated people with a breakthrough infection—not only for logistical reasons but for people to finally gain confidence in the vaccine’s ability to reduce transmission. Many studies show that vaccinated people infected with coronavirus are contagious for less than the currently recommended 10 days of isolation (which still makes sense for unvaccinated people with COVID because non-immune patients with COVID can be contagious for that long.)
The bottom line: once you’ve been vaccinated, you can start to put the fear of COVID behind you. You can (and should) put yourself back in the driver’s seat of your health and wellbeing after you’ve been vaccinated. Schedule your check-up with your primary care doctor. Get back on the wagon with exercise and healthy eating. Put basic self-care back on the to-do list. And please get your flu shot! After all, health is about so much more than simply not getting COVID.
The vaccines and booster shots
The mRNA vaccines continue to be wildly effective against the endpoints we care most about: death and hospitalization (which is not to say we don’t care about infection—we do!)
Breakthrough infections are no longer rare, therefore booster shots have been approved for people at highest risk for severe outcomes from COVID should they become infected despite getting the primary series.
For tired eyes: here is a short video *explainer* about boosters shots that I recorded for Yahoo News.
In brief, Moderna or Pfizer recipients who are over 65 and who are at least 6 months from the second shot need a booster now. Boosters are also recommended for people with chronic conditions or who live and work in settings with increased exposures.
All J & J recipients need a booster shot 2 months after their initial vaccine because the J & J vaccine has been shown to be less effective against death and severe disease than its mRNA cousins. I continue to recommend a single mRNA shot to most of my J & J recipients. (Two doses of mRNA after an initial J & J shot so far isn’t necessary.)
If you are healthy, under age 65, and a recipient of the primary Pfizer or Moderna series, you can feel good that you do not need a booster right now.
Immunity from the mRNA shots is long-lasting.
A new study out of Israel and published in The Lancet last week shows that third doses of the Pfizer vaccine were indeed beneficial to the highest-risk patients. It also showed that, for non-boosted people without underlying medical conditions, the risk of severe disease from COVID was 1 in 32,000. For context, Hopkins infectious disease epidemiologist David Dowdy points out that this risk is similar to the risk of accidental death over the span of 2 weeks in the US.
In other words, there is no need to rush out for a booster if you are under 65 and healthy and don’t work in healthcare or in a school, for example. Could this change? Absolutely! When? If/when we learn that the virus has evaded immune protection from the vaccines—which, so far, it has not.
Kids and the vaccine
The vaccine for kids ages 5-11 is likely to be approved by the CDC this week. Hooray! So far the vaccine looks to be safe and effective for this age group. Hopefully this will relieve some stress on exhausted parents and pave the way for a more normal life for kiddos. (I was glad to be interviewed in this article, out today, about this very issue!)
I personally would not hesitate to vaccinate my 5-11 year-old child ASAP, particularly if my child were at high risk for severe disease. (My three kids are teens and already have been fully vaccinated.) That said, I don’t blame parents for asking questions about the vaccine and/or for waiting for more vaccine safety data given that healthy kids are generally at low (but not zero) risk for severe outcomes from COVID and given that the vaccine studies on kids were small.
What about kids who’ve had COVID or who have antibodies to COVID-19 after an exposure? This is a very complex and contentious issue (h/t Twitter) with no simple answers. As of right now, there’s no clear correlation between antibody levels and the degree of immune protection against disease. In other words, we’re seeing people with high antibody levels get breakthrough infections and people with low antibody levels remain protected—and, of course, vice versa.
It’s only in looking at real-world evidence comparing vaccinated, unvaccinated, and previously-infected populations that we can understand the power of immune protection from past infection versus vaccine-induced immunity.
Which is why I tend to agree with experts like UCSF’s Bob Wachter on this: that a single dose of the vaccine for previously-infected kids might suffice given the real-world evidence (beyond simple antibody measurements) that people who have recovered from COVID-9 itself have some—albeit not consistent—immune protection. However, more data plus clear messaging from the CDC on hybrid immunity (infection-induced plus vaccine-induced immunity) is needed to tailor vaccine recommendations for kids and adults.
I also think it’s reasonable to space out the two vaccine doses further than the “recipe” (that calls for a 3-week interval), since we now know that waiting 6-8 weeks between doses probably elicits the most immune protection from the two shots.
To be clear: I am strongly pro-vaccine, but I think the decision to get vaccinated against COVID should be shared between caregivers and pediatricians—and should not yet be mandated.
The bottom line for me is this: kids can get COVID-19. While they are at relatively low risk for severe outcomes compared to adults, kids can get severely ill from COVID. Kids also need normalcy. And with more widespread vaccination, community transmission should drop thereby allowing us to envision off-ramps for pandemic restrictions. Kids (just like all of us) ultimately will be exposed to the virus. And because the risk of COVID-19 is greater than the risk of the vaccine, I personally would favor vaccination for my 5-11 year-old child.
Testing:
Rapid antigen tests:
Recall that rapid home tests like Abbott’s BinaxNow are highly sensitive for infectious levels of coronavirus in the nose. Getting a negative rapid test before walking into school or Thanksgiving dinner can help prevent us from unwittingly transmitting the virus to others. (Which, again, is a risk that is reduced by getting vaccinated.)
In other words, taking a rapid COVID test before attending any crowded indoor gathering adds another layer of protection, especially for unvaccinated folks in our midst.
Over 30 states are moving toward a long-overdue Test-to-Stay (TTS) protocol that essentially does away with unnecessary quarantines, allowing kids to stay in school after an exposure to COVID-19 as long as they remain symptom-free and their rapid antigen test (done daily or every other day) remains negative. This protocol is critical to reduce further disruptions to school and makes sense given the negligible public health benefit of quarantines and the enormous harms of kids missing school. Last week my friend Emily Oster wrote an excellent blog post about Test-to-Stay, and I encourage all parents, educators, and school boards to take a look!
The CDC is apparently looking into recommending TTS as a standard for all states.
The federal government has invested lots of money to increase access to rapid tests to help people make informed decisions about entering public spaces like schools and workplaces.
PCR tests
These highly sensitive tests are still appropriate in many situations, for example for people with a known close exposure (i.e. household) to COVID-19 who need asymptomatic testing 3-5 days after the last exposure.
I am seeing a boatload of non-COVID viral infections and am happy to offer PCR testing in my office to make a same-day diagnosis of COVID, flu or RSV—or to rule these out in order to recommend appropriate treatment for the myriad circulating viruses for which specific testing isn’t needed (and doesn’t exist). It’s a germy world out there right now!
Antibody tests
I currently use COVID antibody tests for one main reason: to help determine if a patient’s past respiratory infection was COVID-19. In other words, the presence of nucleocapsid antibodies in someone’s blood means that that mysterious “bug” that my patient had at least two weeks ago (and didn’t get tested for) was indeed COVID.
Understandably, many patients are asking me: “Can I get my antibody levels tested to see if I need a booster shot?” or “Can I see how high my antibodies are to know how protected I am?” As I explained above, while checking antibody levels to guide vaccination decisions may seem like a sensible idea, it’s not that simple. There’s also no set standard for what level of antibodies are “required” to declare a patient “immune” or not from past infection or from vaccination. This makes sense biologically: antibodies are only one arm of the immune system, therefore measuring antibodies is only partially assessing the full force of our trained immune system.
This article in JAMA beautifully explains why antibody levels can’t (yet!) be used as a surrogate for immunity—and why clinicians like me need to manage patients’ expectations when asked to check blood antibody levels. The short story? Antibody levels don’t seem to correlate with the level of protection against asymptomatic, symptomatic disease, hospitalization, and death. “The problem isn’t simply that the tests weren’t designed to assess immunity…It’s also that the protective antibodies and their thresholds still haven’t been fully worked out.”
The upshot of this lengthy blog post is this: the vaccines work. They are the path forward. Get vaccinated and boosted if you’re eligible, and know that hope is alive.
I will see you next week. Until then, be well.