Prep for Thanksgiving
When my husband got COVID-19 last Thanksgiving, it set off a cascade of family-wide fear and logistical shenanigans we’d love never to revisit. Thankfully, he recovered fully and didn’t unwittingly infect any of our more vulnerable family members. Though my husband was quite remorseful about getting sick and putting others at risk, we didn’t treat his infection as a moral failure but rather as a reminder of our shared vulnerability to this wretched virus. We battened down the hatches and thanked our lucky stars that we got through it—unlike so many people back in 2020 who weren’t as fortunate.
So this holiday season I’m thankful for the enormous progress we’ve made over the last 20 months. The vaccines—plus rapid testing as needed—can allow us to chow down on turkey and pumpkin pie with loved ones with less fear of either getting COVID ourselves or infecting other people.
Are the vaccines perfect? Not at all. They are preventatives, not bulletproof vests against COVID-19. And, as you know, breakthrough infections are no longer rare because of the highly contagious Delta variant. But once we’ve been vaccinated (and boosted if particularly high-risk), our chance of getting very sick is low and our risk of infecting other people is also significantly reduced.
So how can we congregate at Thanksgiving when the vaccines aren’t perfect, not everyone around the table might be fully vaccinated, and case rates are increasing in parts of the US?
Here is my prescription for optimizing your holiday season:
Get vaccinated if you aren’t already.
By far the best way to protect yourself and others is by getting vaccinated. The vaccines are safe and effective. And now that over 900,000 kids ages 5-11 have been vaccinated without any safety concerns, we can feel increasingly comfortable recommending the shot for this age group. Even a child who’s had a single dose of the vaccine can feel somewhat protected by partial immunity. And healthy children are in a low-risk category for severe outcomes just by being kids.
Get boosted if you’re at high risk.
The data are clear that certain populations are at higher risk for more serious outcomes from COVID-19 in the event of a breakthrough infection. These are:
people over age 65;
people with underlying health conditions like obesity and heart disease;
people who are immunosuppressed; and
people with certain occupational risks and who live in long-term care facilities
For weeks I’ve been recommending to these patients a third dose of Pfizer or Moderna (either one!), six months after the primary Pfizer or Moderna series, in order to reduce the risk for hospitalization and death. I’ve also been recommending a single Pfizer or Moderna shot to all J&J recipients because of the lower overall vaccine effectiveness of J&J when given as a single shot.
Consider getting a booster shot even if you’re not high risk.
The question of “boosters for all” is the hot topic du jour. I’ve been noodling on it all weekend, reading the emerging data and discussing it with friends and colleagues.
At the end of the day, I largely agree with Paul Sax MD’s blog post for the New England Journal of Medicine (in which he quoted my distress over the confusing messaging on boosters). I think that a booster shot for healthy adults makes sense at this moment. It can’t hurt and it will reduce the risk of symptomatic infection.
My problem with the “boosters for all” public health strategy is that it isn’t ultimately the way out of the pandemic. Rather, the path forward is vaccinating the unvaccinated and distributing vaccine doses around the world in order to choke off the virus’ ability to mutate and evade immune protection from the vaccines (which, so far, has not happened). In other words, we’d all be safer if more people got dose number one instead of already-immune people getting dose number three.
But the reality is this: we still have a large proportion of the US population who simply won’t get vaccinated; cases are surging in certain areas of the US; winter will push more people indoors where transmission is more likely; and we’re in the luxurious position of having lots of vaccine doses in the US but without the personal agency to push vaccine doses abroad.
In my opinion it isn’t wrong to boost healthy people; it’s just not an elegant public health strategy (i.e., you don’t see many people posting booster selfies on Instagram!)
So, I got my third vaccine dose, fully aware of the marginal benefit to myself and others when compared to the enormous benefit of that same dose to an unvaccinated person. I will continue to help dispel myths and bring facts to people who are vaccine-hesitant and to lobby for global vaccine equity. But, in the meantime I am glad to have taken the extra precaution.
Indeed, it’s important to manage people’s expectations of what a booster shot can and cannot do. Recall that the primary vaccine series remains strongly effective against death and severe disease for people under 65 without comorbidities but does drop in effectiveness against infection over time. But new real-world data out of England shows greater than 90% vaccine effectiveness against symptomatic infection when comparing boosted vaccinated people to unvaccinated people.
In other words, a booster can:
further reduce the risk of a breakthrough infection (which, for most already-vaccinated people, usually consists of a mild illness) and
further reduce the risk of transmitting the virus to other people (which, for most non-sick, already-vaccinated people, is already low)
From a psychological standpoint, a booster shot can improve our sense of agency and allow us to engage more fully in normal life—or at least it should. (And, in my opinion, a booster shot should allow us to unmask given that the risk of transmitting the virus to other people after three shots is exceedingly low.)
These are good reasons to get a booster shot, especially when the risks of the vaccine are tiny. That said, the risks are not zero, which is why, for example, I won’t boost my 17-year-old son right away because of the rare but real risk of vaccine-related myocarditis from the mRNA shots in young men and teen boys and because he already is low risk for severe outcomes from COVID give his age, general health, and vaccinated state.
You also don’t need a booster shot if you’ve had COVID from a breakthrough infection. Recovering from COVID means that your immune system has “seen” the virus and has mounted a successful immune response that offers extra protection akin to (and possibly better than) getting a third vaccine dose.
To be clear: an extra dose of vaccine—like recovering from a breakthrough infection—doesn’t render us bulletproof. (Though it’s pretty darn close!) It simply stimulates our immune system to make a fresh batch of circulating antibodies (the level of which will, as expected, wane over time like the first two batches of antibodies do), and it reminds our B and T cells to be ready for the real thing should we be exposed.
As you know, the coronavirus ultimately will become endemic like the flu, RSV, and the other four coronaviruses. We must accept the unpleasant reality that coronavirus is here to stay, and we’ll all be exposed at some point. This is not to say we should throw caution to the wind or no longer care about ongoing death and destruction. Hardly!
Coronavirus’ ubiquitous presence in our lives simply makes it easy to argue for widespread boosting; indeed it’s something we can do—and it’s a heck of a lot easier to take a third dose ourselves than it is to convince unvaccinated people to take the vaccine or to donate our vaccine doses to other parts of the world in need of first doses.
The bottom line: I recommend getting a booster shot—it doesn’t matter which one—six months after the last dose of Pfizer or Moderna. For people who had J&J followed by a single Pfizer or Moderna, we don’t yet have a “protocol” for you but it’s not a bad idea to get dose number two of either of these mRNA shots. This should of course be a shared decision (like all of the above!) between you and your primary care doctor.
Note that I’d probably wait at least six weeks to get dose number two of either of the mRNA shots. Why? Because data show that extending the duration between doses by 6-14 weeks with the Pfizer vaccine—therefore likely the Moderna vaccine, too—increases the immune response. (Note: it's fine to stick with the standard recipe of 3-4 weeks between doses.)
Will we need boosters every six months, every year, in perpetuity? We simply don’t know. Remember that we’re building this airplane in the air, watching the currents and conditions in real time. The worst case scenario is that we do need boosters every year or so like we already do for the flu. Most importantly, we’re not seeing the virus evade immune protection from the vaccines. We simply need more people to get vaccinated to contain the global spread—and to boost our most vulnerable populations now to prevent needless death and suffering.
How else to protect yourself and your loved ones at Thanksgiving?
Stock up on rapid antigen tests.
Recall that the rapid antigen tests like Abbott’s BinaxNow are essentially “contagiousness” tests. While they’re not cheap, they do a great job of answering the question: “Do I have enough coronavirus in my nose to infect another person today?” They help protect other people from the test recipient who might be carrying the virus in their nose and not know it (the risk of which is reduced, but not eliminated, after vaccination).
So for added protection against transmitting the virus to someone else, I’d consider rapid antigen testing right before any higher-risk activity or when interacting with higher-risk individuals. For example, you might test an unvaccinated or partially-vaccinated child before sitting at the Thanksgiving table with an elderly family member to reduce the risk of accidentally infecting that person. Of course if that elderly family member is vaccinated and boosted, his or her risk for severe outcomes from COVID-19 is dramatically reduced already, but a negative rapid antigen test can offer added peace of mind.
This weekend I traveled to Indianapolis to watch my rock ‘n’ roll cousin Hamilton Leithauser perform live and to join the “bubble” of his touring company. I had to show proof of vaccination for the concert hall. Then I took a rapid antigen test before going backstage and onto the tour bus. It was worth it!! There’s nothing better than live music, family bonding, and enjoying slivers of normalcy.
Gathering with family and friends is part of being healthy. Just as we’re wired for survival (hence the surge of adrenaline we feel when faced with a threat to our safety), we’re also wired for social connection. After 20 months of life interrupted, togetherness is more important than ever.
As we look ahead toward the holiday season, it’s important to protect ourselves from disease and despair in tandem. We can do both. By getting vaccinated (and boosted if needed/desired), we’ve taken the best step toward protecting ourselves and othefrs from COVID-19. And by convening with loved ones, we can start to heal from the collective trauma of the last 20 months. (Unless, of course, you talk politics—in which case you’re on your own!)
Meanwhile, it’s critical to recognize how far we’ve come since March 2020. Despite currently rising case rates in Europe and in parts of the US, there’s light at the end of the tunnel. Now that kids are eligible for the vaccine and with two game-changing oral antiviral medications soon to be approved, we are slowly but surely getting to the other side.
I will see you next week. Until then, be well.