Prep for BA.2
Birds are chirping, cherry blossom buds are popping, and the phones at my office are buzzing with questions:
Should I get a 4th shot?
If I had Omicron already, am I protected from BA.2?
Should I be worried about this new variant?
These are excellent and appropriate questions as we emerge from the first Omicron wave and prepare for the next. Indeed, more BA.2 is en route to the U.S. It’s actually already here.
Let’s first recall that when Omicron was originally identified in November 2021, we knew back then that it had multiple subtypes: BA.1 has been the predominant strain in the US for the last three-plus months; BA.2 is the dominant strain in Europe at the moment—and soon will be here, too. In other words, BA.1 and BA.2 both are Omicron.
So, what does that mean for you?
Let’s break that down into three critical questions:
Is BA.2 more contagious than BA.1? Yes. So far it looks to be more transmissible (i.e. easier to catch).
Is BA.2 causing more severe disease compared to BA.1? So far, no. BA.2 looks not to cause more serious disease on a person-to-person basis. In other words, if you were to get infected with BA.2 this spring, you likely wouldn’t be any more or less sick than if you’d had Omicron in, say, December.
Is BA.2 resistant to the vaccines? So far, no for the outcomes we care most about. Data out of Britain and Qatar show that people who have been vaccinated—and people who are older or are at higher risk who have been boosted once—are still at very low risk for hospitalization and death from COVID-19.
Overall, this is good news. Of course we’d love COVID-19 to go away entirely, but that option isn’t on the menu. We can expect future waves of COVID-19 much like we expect intermittent hurricanes. In short, as BA.2 rolls in, we need protective gear that is similar to—but much more precise than—what we’ve been using since COVID arrived.
So what are the solutions?
The solutions at a population level are to:
vaccinate the world
increase access to oral antiviral medications like Paxlovid for high-risk patients
increase access to Evusheld (the twice yearly injection of monoclonal antibodies used as a preventive measure for high-risk patients)
better ventilate public spaces like schools and office buildings
make rapid antigen tests more widely available
emphasize the importance of high-grade masks for people who want or need added personal protection based on their unique medical conditions and risk tolerance; and
restructure our healthcare system to allow all Americans access to patient-centered primary care to get nuanced advice on everything from COVID and cancer prevention; anxiety and Alzheimer’s disease; diabetes and depression. (I’ll be dead before this happens, but a girl can dream!)
The solutions for individuals are to:
get vaccinated if you’re not
get boosted if you and your physician think it’s necessary and appropriate given your age, immune status, underlying health conditions, and past infection with SARS-CoV-2
work on your underlying health conditions (for example, obesity is a top modifiable risk factor for serious COVID outcomes which is one of the many reasons I’m working hard with my many patients who struggle with weight on realistic nutrition plans, sustainable ways of getting movement, and understanding their relationship with food)
wear a high-grade mask and/or take a rapid antigen test if you want or need to depending on your health issues, immune status, and anticipated potential level of exposure to the virus; and
stay home and call your doctor if you’re sick. (With allergy season upon us, it’s important to distinguish between sinus congestion from inhaling pollen versus a mild case of COVID—with, for example, COVID testing for people who aren’t sure.)
Let’s break down the question about booster shots a bit more. First off, there is no one-size-fits all prescription for whether or not to get boosted for the first time, not to mention a second time. Moreover, the booster decision is increasingly complex as more and more people have some degree of immunity from prior infection.
Meanwhile Pfizer already has asked the FDA to authorize a fourth shot of the original vaccine for people over age 65, and Moderna promptly did the same, seeking approval for a fourth shot for all adults.
As I’ve written about extensively, immunity to a virus comes either from a) vaccination, b) infection itself, or c) both. We’ve learned over the last two years that neither vaccine-induced nor infection-acquired immunity is perfect. In other words, people who are vaccinated against COVID can still get infected, and people who have recovered from COVID can still get re-infected.
To be clear: I am not saying “Go get infected!” Hardly. I’m simply saying that we must acknowledge the reality that many people in this country do have some degree of immune protection from having been infected. Moreover, millions of Americans have Omicron-specific immunity from having had COVID due to BA.1 in the last three months. And it’s important to know that the immunity from BA.1 does seem to offer protection, albeit imperfect, against BA.2 according to the WHO.
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-19 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 give you two examples:
Example One
My patient in his 70s with type-2 diabetes is triple-vaccinated and had COVID-19 in December. He was pretty sick back then but didn’t need hospital care. He called me last week to ask if he should get a fourth shot.
My answer: Not yet.
Why? With three shots and a recent infection with Omicron (BA.1) itself, his body has had FOUR exposures to the spike protein (three vaccines and the spike protein of the virus itself) and one exposure to the whole virus, giving him robust protection against death and hospitalization from reinfection with, say, BA.2 should he be unlucky enough to get COVID again. In other words, getting a fourth shot (i.e. a fifth exposure to the spike protein) isn’t going to add much value. He would certainly get another transient “bump” in antibody levels but, as you savvy readers well know, antibodies are only one small piece of the immune system, and they always wane over time. What largely protects us from serious outcomes from COVID-19 is cellular immunity (i.e. memory B-cells that make fresh batches of antibodies when we’re exposed to the virus and T-cells to sweep away virus-infected cells).
So when would I recommend this patient take a fourth shot (aka a “second” booster shot or a 5th “reminder” to his already-primed immune system)? I might suggest he do it If:
We had evidence that the upcoming variant evaded vaccine-induced protection. In other words, I’d recommend another shot if we saw a variant on the horizon different enough from past variants that it put him at high risk for serious outcomes from COVID-19 like he was before he was vaccinated and boosted. Indeed, people over 65 with risk factors like diabetes are proven to be at higher risk for serious outcomes if they are NOT immune and/or NOT boosted in the first place. In other words, if you haven’t had your third shot and you are over 65 and/or have underlying conditions, please go get it!
He hadn’t essentially been “boosted” (again) by getting Omicron itself. Having had COVID with an Omicron (BA.1) infection in December already primed his immune system to handle a BA.2 infection. In other words, I am starting to recommend a second booster shot to high risk and to patients over 65 who have not yet had COVID, but this is an individualized decision based on the patient’s unique medical conditions and circumstance. The problem? The FDA hasn’t yet approved it.
He had a more serious immunocompromised condition that rendered his immune system less able to mount an appropriate response to the vaccines or infection—but instead of a fourth shot I’d probably just order him Evusheld and make sure he identified a pharmacy to get him Paxlovid if he got COVID again.
We had a NEW vaccine formulation that specifically targeted the circulating variant—similar to how we formulate the flu shot each year, i.e. tailored to the dominant variants. Pfizer and Moderna are both working on Omicron-specific boosters.
You might be thinking to yourself, why not recommend a booster to this guy? Why not save yourself the mental gymnastics and just give this dude another shot in the arm?
Well, the book I’d love to write some day would be called “Just Because We Can, Doesn’t Mean We Should.” The Cliffs Notes to it are this: To recommend any medical intervention, the benefits must outweigh the harms.
And in the case of COVID-recovered triple-vaccinated person, the benefits of a second booster aren’t clear. Yes, he’d get a transient boost of antibodies, but he already got this with the Omicron infection, so what would that actually achieve? If we thought it would prevent him from ever getting COVID-19 again, we might do it. But it won’t.
To remind: The vaccines are not sterilizing. Neither the vaccines nor a past infection perfectly prevent (re)infection; they simply help reduce the risk of serious outcomes. We see people getting COVID twice and even three times. The vaccines are extraordinarily safe, but between missed work days due to transient vaccine side effects to mismanaged expectations of what more and more shot doses with the original strain of SARS-CoV-2 can do for us, it’s important we think carefully before assuming that “more is more.”
To be clear: I am very pro-vaccine. Just like I am very pro-medication. But I wouldn’t automatically treat your high cholesterol with Lipitor if we could manage your heart attack risk by cutting out bacon and exercising more often—even if Lipitor was completely harmless (which it isn’t).
In other words, I love the COVID shots. I love Lipitor. But context always matters. Make sense?
Example Two
My healthy 50 year old patient who has had three shots, has not yet had COVID, and has a big family reunion coming up in May. She called me to ask if she should get a fourth shot to protect herself and her unvaccinated family members from COVID-19.
My answer:
The best way for the unvaccinated family members to protect themselves from serious outcomes from COVID is to get vaccinated themselves.
The vaccines continue to do a great job of protecting the vaccine recipient from serious disease, but we currently don’t have great evidence that a fourth vaccine dose further reduces the risk of death and hospitalization from COVID in healthy people.
In the Omicron era, the vaccines are not great at preventing infection and are not great at preventing transmission like they were pre-Delta. In other words, she could still get infected and/or sicken others even after a fourth shot. Would the risk of that happening be less? Maybe so. But the incremental benefit of four shots versus three is probably tiny.
If she insists on getting a fourth shot to boost her antibody levels in advance of a big event, I wouldn’t stop her; I’d just want her to be clear on expectations—including the fact that the FDA hasn’t yet approved them for all. (See: book title above).
In sum, the vaccines are exquisitely effective at doing what they do well. But they don’t provide an impenetrable wall against COVID-19. They are not a magic force field. Which is why, at this moment of relative COVID quiet, we need to zoom out on our health, manage our underlying health issues, and schedule our routine check-ups (here I am last week doing just that).
As we manage our expectations about the COVID vaccines, we must also accept the unpleasant reality that COVID is here to stay. We’ll continue to see wave after wave. We cannot control the inevitability of its existence—nor should we be surprised when BA.2 is dominant, when case rates go up, and when hospitalizations and deaths do, too. Because they will—particularly among unvaccinated and non-immune high-risk populations and patients. Yet as the Surgeon General said just yesterday, we don’t need to let COVID “define our lives.”
This is not to say we give up—or become immune to all the suffering. Not at all. As I wrote last week, we are not done. It’s time to surge resources to our highest-risk populations and work on larger structural problems that brought us here while at the very same time we work on things that are under our own control and recognize the things that aren’t. Holding paradox—that is, the complexity of both-and—is more essential than ever.
Margaret Renkyl captured the moment beautifully in her New York Times opinion piece:
“It’s entirely possible to understand what human beings are doing to the woods—and to one another in this moment of dread and grief and terrible struggle—and still exult in birdsong and tiny blooming flowers peeking out from the dead leaves of autumn.”
I will see you next week. Until then, be well.