COVID-19 Update

Two pieces at WaPo today.

note: Good luck sorting through this shit. My take is that I'm old and fat, and even though I'm all vaxxed up and I've never had COVID, I'll be going for a 2nd booster because that's what I think makes sense to me - and cuz my doctor said so - unless he's changed his mind - again.

(pay wall)

Opinion: How allowing a second booster shot signals a shift in pandemic guidance

The Food and Drug Administration’s decision on Tuesday to authorize a fourth coronavirus vaccine dose for Americans older than 50 heralds a new approach to the pandemic. Instead of the federal government prescribing actions that everyone should take, it is providing tools so that individuals can choose their own level of protection.

The FDA’s announcement, and the Centers for Disease Control and Prevention’s subsequent green light, has provoked a mixed response. Some criticized the process; unlike previous vaccine authorizations, independent advisers to the FDA and CDC have not yet weighed in, and in fact are scheduled to meet next week to discuss exactly this issue. Others applauded the expedited timeline, especially as the CDC just reported that the extremely contagious BA.2 omicron subvariant has become the dominant strain in the United States.

The medical community itself is split over whether a fourth dose is needed. That’s because there is no consensus about the purpose of vaccination. Is it to prevent severe disease? Or is it to reduce any symptomatic illness?

If the goal of vaccination is to prevent hospitalization and death, the vaccine plus one booster should be sufficient. A CDC study found that two doses resulted in an 88 percent reduction in being on a ventilator or dying; three doses increased the protection to 94 percent. During the period when the original omicron strain was dominant, the effectiveness of two doses dropped to 79 percent, while that of three doses stayed at 94 percent.

If the goal is to reduce any infection from covid-19, it’s more complicated. On the one hand, it’s clear from a large analysis in California that the effectiveness of three doses against omicron wanes over time (though protection against hospitalization remains strong). But while preliminary data out of Israel shows that a fourth dose increases antibody levels among people 60 and older, a separate study suggests only marginal benefits in reducing illness for younger health-care workers. Other Israeli studies show that a fourth dose enhances protection against severe illness, but the added benefit might not last long.

Here’s where we need to separate the public health perspective from the individual patient one. From a population health standpoint, I think fourth doses won’t change the trajectory of BA.2 in the United States. About half of those eligible for the third dose have not yet received them, including 1 in 3 adults 65 and older. And of course, there are those who remain totally unvaccinated. Getting vaccines to these groups should remain the priority of health officials.

A permissive allowance is therefore the best policy. Individuals aren’t required to get the extra vaccine, but they can if they wish. In a sense, the decision for an additional booster becomes similar to continued masking or rapid tests before indoor gatherings. There are many Americans who are no longer concerned about covid-19. Those who are vaccinated and boosted might not opt for an extra booster at this time, just as they could choose not to mask or regularly test. This is especially true if they recently recovered from omicron.

There are others who remain worried about coronavirus infection. For the elderly and for the medically frail who would end up in the hospital with any respiratory infection, I understand the rationale for choosing the additional shot. They want to do everything they possibly can to avoid contracting covid-19. Even if the added protection might not be much more than the third and might not last long, it’s worth it.

Separately, there are those who received one-dose of the Johnson & Johnson vaccine and then an initial booster of either J&J or an mRNA vaccine. The CDC is allowing all of these individuals, regardless of age, to receive a second mRNA booster shot if it’s been four months since their last vaccine. To me, this additional booster should be weighed the same way as a fourth dose of an mRNA vaccine — an option for those who wish to further reduce their risk.

Is there a downside to the extra shot? There is a theoretical possibility that if too many boosters are given, one’s body might not mount as much of a response in the future. A more practical reason to hold off is timing: If protection is short-lived, perhaps it’s better to wait until we know for sure that a major surge is coming. Also, omicron-specific boosters are being developed and might be available in the coming months. Some might choose to wait until then, or until there’s clear evidence that immunity against severe illness is waning.

The point is that while it’s far from straightforward whether people need a fourth dose, there are those who want it and should be able to access it. The federal government’s stance to allow this option signals an important pivot away from top-down public health guidance to individual decision-making. Going forward, people should be empowered to use boosters — just as they do masks, tests and treatments — to manage their own risk of covid-19.

- and -

(freebie)

Older adults can get second coronavirus booster to strengthen waning protection

Older adults can get second booster shots of the Pfizer-BioNTech and Moderna coronavirus vaccines, federal agencies announced Tuesday as they expanded access to additional shots to help shore up protection against severe illness.

The Food and Drug Administration authorized a second booster shot of the Pfizer-BioNTech and Moderna coronavirus vaccines for people 50 and older at least four months after their first booster. The FDA also updated its authorization of additional doses for people 12 and older who are immunocompromised, saying they are eligible for another booster shot — the fifth inoculation for people at heightened peril from the virus.

The shots are not a permanent solution to the pandemic. But with a still-more-transmissible version of the omicron coronavirus variant becoming dominant in the United States, even a short-term immunity boost among those at risk of severe illness could provide a valuable layer of protection.

The FDA action was followed within hours by a statement from the Centers for Disease Control and Prevention updating its booster guidance.

The second booster for adults 50 and older and for people 12 and older who are immunocompromised is expected to become available as early as Wednesday, now that the CDC has updated its guidance allowing those individuals to get it.

“This is especially important for those 65 and older and those 50 and older with underlying medical conditions that increase their risk for severe disease from COVID-19 as they are the most likely to benefit from receiving an additional booster dose at this time,” CDC Director Rochelle Walensky said in a statement.

Outside experts have debated the age at which second boosters should be made available. Many scientists who support a fourth dose for some older adults see little evidence that people under 60 or even 65 would clearly benefit. Federal officials said they were expanding eligibility to a lower age to avoid confusion and because underlying health risks were relatively common among people older than 50.

There are about 118 million people age 50 and older in the United States. But because not all of the people in that age range have received the initial series of shots or boosters, only a fraction are immediately eligible for a fourth shot.

Booster uptake in the United States has been slower than desired, particularly among older Americans who are at higher risk of severe illness. About 15 million people age 65 and older — a third of people in the age group — are fully vaccinated but have yet to receive a first booster. Only about 40 percent of people between 50 and 64 have received a first booster.

“I would urge people to get their first booster because one thing that did become apparent … is the third dose provides a differentiating level of immunity that does seem to provide people some additional benefit, in terms of preventing the severe outcomes of hospitalization and death — and that seems to last and be more durable,” Peter Marks, director of the FDA’s Center for Biologics Evaluation and Research, said at a news briefing.

The messenger RNA boosters will be available to people regardless of which brand of coronavirus vaccine they initially received, including Johnson & Johnson recipients.

The Pfizer-BioNTech booster is authorized for immunocompromised people age 12 and older. The Moderna vaccine has not yet been authorized in teenagers, and its booster is authorized for immunocompromised people 18 and older.

Experts have been inundated with questions from family members and emails from the public seeking advice on boosters.

“I’ve been getting multiple inquiries from lay friends over the past few days: ‘What does this mean, and what should I do?’ ” said John P. Moore, a professor of microbiology and immunology at Weill Cornell Medicine in New York. “I find it increasingly difficult to tell friends what they should do. It’s becoming really problematic.”

The primary benefit of a fourth shot is thought to be protection against severe illness, and that risk can vary dramatically among people 50 and older. Not all experts are convinced the benefits are clear, and some have debated about whether the age cutoff should be 60 or older. A matrix of factors — including underlying health conditions, age, and time since last booster dose or infection — could play a role in what a person should consider in risk vs. benefit.

A 70-year-old with diabetes and high blood pressure, for example, who received a booster dose in October probably would be at dramatically different risk from covid-19 than a 50-year-old with no underlying health conditions. Tens of millions of people were infected with the omicron variant during the winter surge, and those people’s immune systems have been effectively boosted — so they may not need another shot now.

Some experts have raised concerns about the decision-making process. The second booster issue is not scheduled to be presented to outside committees advising the FDA and CDC.

“I think it’s wonderful that the FDA is making [a second booster] available,” said William Schaffner, an infectious-diseases expert at Vanderbilt University and a liaison member of the CDC’s Advisory Committee on Immunization Practices. But Schaffner said such decisions are typically reviewed by the CDC’s advisers, “and I think that mechanism should have been used for this also.”

Even if outside experts reached a similar conclusion, having a discussion and seeing data presented at a public meeting offers transparency and a “different tone,” Schaffner said.

But the FDA news is certain to be welcome to a segment of the population “who will be at their doctor’s office or pharmacies tomorrow, if not this afternoon, getting their fourth dose,” Schaffner said. “But they will be the minority of the population because after all, before you get your fourth, you have to get your third.”

Evidence in support of a fourth dose is limited and mixed, based largely on data from Israel — where people 60 and older have been able to receive a second booster shot. Israeli studies have supported the idea that an additional shot could be lifesaving for people older than 60 but have also suggested the shots will have marginal benefits for young, healthy people and offer only short-term and modest protection against getting infected.

One preprint study from Israel, out of 328,597 people who received a second booster dose, 92 died from covid. That outcome was significantly better than in the group of 234,868 who received only one booster; in that cohort, 232 died from covid. Another preprint found a lower rate of severe illness among people older than 60 who received four shots, but was limited, covering only a two-week period in late January.

Data included in a letter to the editor of the New England Journal of Medicine provided a more mixed picture. Among health-care workers in Israel, a fourth shot increased virus-blocking antibodies. But that boost provided little protection against infection, and people who became infected experienced few symptoms regardless of whether they had received three or four shots. Vaccinated people had relatively high amounts of virus in their nose, suggesting they could pass the infection to others.

The Israeli data underscored that boosters’ effects are transient and that a fourth-dose strategy is a short-term approach. An Israeli preprint study published last week before peer review found that a fourth dose was 73 percent protective against severe illness compared with three doses over the course of 10 weeks of follow-up. But the protection against infection was modest and short-lived, peaking at 64 percent three weeks after the vaccination and falling to about 29 percent.

Marks acknowledged the data supporting a fifth dose for immunocompromised people was more limited but said that it was seen as a way to protect vulnerable people. Vaccines tend to generate weaker protection against covid-19 in this group of people, and that protection tends to erode more quickly.

Timing the shots’ peak protection to the time of greatest risk from the virus is tricky. No one knows when future variants will emerge, and scientists are uncertain even about known threats. Infections from the BA.2 version of the omicron variant are ticking upward in the United States, but some health officials have said they don’t expect BA.2 to cause a surge. Some experts predict a surge next winter.

In terms of giving a second booster, Moore said, “Should you do it now — and in the fall? Or in the fall — and not now? This is where it gets head-spinning. What is the long-term intent, and what is the long-term policy?”

Separate from Tuesday’s action, the FDA plans next week to convene external advisers who will debate the long-term booster dose strategy for the general population. One possible scenario, Marks said, is a fall booster campaign that coincides with annual influenza shots.

White House spokeswoman Kate Bedingfield said there is sufficient supply to offer a fourth dose to limited populations.

“What I would say is that if it at some point it becomes recommended that the full population get … a fourth shot, we’re going to need additional funding,” Bedingfield said.

Vaccine makers are working on shots they believe will provide more durable protection. In recent days, leaders from Pfizer, and German partner BioNTech, and Moderna have indicated they believe new versions of their vaccines, including formulations that incorporate two versions of the coronavirus, will create longer-lasting immunity.

“I think about my family — my loved ones, and what I would say. … I would probably tell them to just kind of hang back until there’s clear evidence of a rise in their area,” said Natalie Dean, a biostatistics expert at Emory University’s Rollins School of Public Health in Atlanta. “There’s something to the timing of it — and where numbers remain low and they’ve been boosted not that long ago, a few months ago, I wouldn’t go out and tell them they need that right now.”