Thank you for this. I am in for five and hoping we get to one a year for those who need it or for all of us. Really hoping this virus stops throwing curve balls. We all need a break!
1. At risk people (those who would be hospitalized for any reason in a typical 6 month period) probably benefit from routine boosting at this point, even if it just decreases risk of infection for a couple of months.
2. The bivalent doses are 50% of each strain. So your body has only seen this omicron part once, and in a smaller dose. They should have done full throttle omicron-only booster, in my opinion.
Do you have any idea of when we might receive more guidance about routine boosting, since in February or March it will have been six months since the bivalent booster for some of us? For a middle aged person who is considered at high risk of severe disease, would there be any drawback to taking a second bivalent? There is a lot of noise about the impact of multiple vaccines. Thank you for your outstanding and accessible newsletter and your service to the community.
I have no idea. I assume a 2nd bivalent would be in order for many. I would prefer it be a monovalent ALL Omicron formulation, since I really don't see the benefit (and see downsides) of continuing to remind the immune system of the Wuhan strain, which is long gone.
I think it depends on the person, but generally speaking, the risk is far lower than it was. But it's not low enough, obviously. The question is who needs boosting and how often? I think the answer is that there are populations who would probably benefit from boosting 2x per year for the next year or two, and other groups for whom that might be helpful, but the help is small enough that we need to carefully assess pros/cons.
I appreciate how you acknowledge the modest reduction in absolute numbers of 65+ hospitalizations. The rate is so much more favorable at 1:2200 instead of the much scarier 1:200 previously.
I am also a big fan of the relative risk reductions, as a 90% reduction in hospitalizations, and an 86% reduction in deaths in the Israeli study sounds convincing.... even as the absolute numbers are less impressive.
It seems like the emerging evidence has been disappointing for repeated boosters and better protection against long Covid. Seems like that is plateauing. Makes me more motivated to recommend Paxlovid/remdesivir which I believe was shown to reduce long Covid by 25% in older patients, and probably more like 40-50% I’m guessing in middle aged patients who are the most likely to develop long Covid. No data on this age group that I’m aware of.
Offit is still dug in against the data with his booster op-ed downers. Eric Topol’s recent post on Ground Truths addresses this problem directly towards the end.
And finally, I think 5 or so studies of neutralizing antibodies show superiority of the bivalent boosters over the original boosters, with neutralization titers against live virus being 2-8X higher. This includes against BA.1.5 and XBB. Real world outcomes and T cell immunity markers I’m not sure but would seemingly be better based on this data you presented here.
Not regretting my bivalent booster, for myself, family, and persuaded patients!
Thanks Ryan. I am skeptical but open to change opinions on pax or remdesivir for long covid. I think there's a chance that meds like these could work, but I just don't think 5 days or treatment would suffice. A longer regimen with very clearly defined outcomes needs to be studied for all of these. Metformin might turn out to be the one--which would surprise the heck out of me, but seems to be where the research miiiight be headed.
We also have to consider viral resistance, which indeed is starting to crop up. A bunch of resistant mutations may not be caused by paxlovid or remdesivir, but they'll be favored by them: https://www.science.org/doi/10.1126/scitranslmed.abq7360
Meanwhile, I think there is such a thing as being over-boosted (imprinting being the main downside; thankfully myocarditis has been extremely low with boosters). But for the types of patients in the Israel study, we are nowhere near that point, and for people with any risk of hospitalization, boosters should be advised.
For younger people, the short-term infection decrease from boosters may be worth it to some, and not to others. I think Paul's essay is correct in that the vaccines we currently have are way too transient in their effect to be reliable for preventing mild disease. What he does not say directly (at least I don't think so), is that pundits over-playing that they do prevent infections better and longer than they do might be holding us back from an Operation Warp Speed for pancoronavirus vaccines that might work far better.
Thank you for this. I am in for five and hoping we get to one a year for those who need it or for all of us. Really hoping this virus stops throwing curve balls. We all need a break!
Waiting to hear if seniors should receive another boost of the bivalent after 6 months…
I would not be surprised, and on two counts.
1. At risk people (those who would be hospitalized for any reason in a typical 6 month period) probably benefit from routine boosting at this point, even if it just decreases risk of infection for a couple of months.
2. The bivalent doses are 50% of each strain. So your body has only seen this omicron part once, and in a smaller dose. They should have done full throttle omicron-only booster, in my opinion.
Do you have any idea of when we might receive more guidance about routine boosting, since in February or March it will have been six months since the bivalent booster for some of us? For a middle aged person who is considered at high risk of severe disease, would there be any drawback to taking a second bivalent? There is a lot of noise about the impact of multiple vaccines. Thank you for your outstanding and accessible newsletter and your service to the community.
I have no idea. I assume a 2nd bivalent would be in order for many. I would prefer it be a monovalent ALL Omicron formulation, since I really don't see the benefit (and see downsides) of continuing to remind the immune system of the Wuhan strain, which is long gone.
Thanks for responding. I hope this idea of a monovalent Omicron vax is being considered at the upcoming FDA meeting.
One more question...are we at a point where we can fear this virus less from an outcome perspective?
I think it depends on the person, but generally speaking, the risk is far lower than it was. But it's not low enough, obviously. The question is who needs boosting and how often? I think the answer is that there are populations who would probably benefit from boosting 2x per year for the next year or two, and other groups for whom that might be helpful, but the help is small enough that we need to carefully assess pros/cons.
I appreciate how you acknowledge the modest reduction in absolute numbers of 65+ hospitalizations. The rate is so much more favorable at 1:2200 instead of the much scarier 1:200 previously.
I am also a big fan of the relative risk reductions, as a 90% reduction in hospitalizations, and an 86% reduction in deaths in the Israeli study sounds convincing.... even as the absolute numbers are less impressive.
It seems like the emerging evidence has been disappointing for repeated boosters and better protection against long Covid. Seems like that is plateauing. Makes me more motivated to recommend Paxlovid/remdesivir which I believe was shown to reduce long Covid by 25% in older patients, and probably more like 40-50% I’m guessing in middle aged patients who are the most likely to develop long Covid. No data on this age group that I’m aware of.
Offit is still dug in against the data with his booster op-ed downers. Eric Topol’s recent post on Ground Truths addresses this problem directly towards the end.
And finally, I think 5 or so studies of neutralizing antibodies show superiority of the bivalent boosters over the original boosters, with neutralization titers against live virus being 2-8X higher. This includes against BA.1.5 and XBB. Real world outcomes and T cell immunity markers I’m not sure but would seemingly be better based on this data you presented here.
Not regretting my bivalent booster, for myself, family, and persuaded patients!
Thanks Ryan. I am skeptical but open to change opinions on pax or remdesivir for long covid. I think there's a chance that meds like these could work, but I just don't think 5 days or treatment would suffice. A longer regimen with very clearly defined outcomes needs to be studied for all of these. Metformin might turn out to be the one--which would surprise the heck out of me, but seems to be where the research miiiight be headed.
We also have to consider viral resistance, which indeed is starting to crop up. A bunch of resistant mutations may not be caused by paxlovid or remdesivir, but they'll be favored by them: https://www.science.org/doi/10.1126/scitranslmed.abq7360
Meanwhile, I think there is such a thing as being over-boosted (imprinting being the main downside; thankfully myocarditis has been extremely low with boosters). But for the types of patients in the Israel study, we are nowhere near that point, and for people with any risk of hospitalization, boosters should be advised.
For younger people, the short-term infection decrease from boosters may be worth it to some, and not to others. I think Paul's essay is correct in that the vaccines we currently have are way too transient in their effect to be reliable for preventing mild disease. What he does not say directly (at least I don't think so), is that pundits over-playing that they do prevent infections better and longer than they do might be holding us back from an Operation Warp Speed for pancoronavirus vaccines that might work far better.
Good points, thank you!