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COVID-19 Update 2/23: Vaccine Guidelines, New Monoclonals, and More

February 23rd, 2022 | 10 min. read

By Steve E. Bishop, M.D.

COVID-19 Update 2/23: Vaccine Guidelines, New Monoclonals, and More

On this week's COVID-19 update, Dr. Bishop reviews the current vaccine guidelines, discusses a new monoclonal antibody treatment, and more. Watch the video below or read on for the full recap. 

Reviewing Vaccine Guidelines

The main thing I wanted to focus on was regrouping and updating everybody on what's going on with vaccines and boosters and all that.

There's been a lot of stuff out there lately, and I think a lot of people are confused about what they should be doing and when. When do I need a booster? Do I even need a booster? What needs to be done?

I thought we would just take some time and walk through all of this again for everybody because there have been changes and it's a good thing to revisit from time to time.

So the first link here is to the CDC's website. It's their "Staying Up to Date" page on vaccinations. I'm just going to walk through it.


This first thing here is what's recommended for people who are otherwise in generally good health. They're not immunocompromised or anything like that. Don't have anything wrong with their immune system and are expected to respond appropriately or normally to a vaccine.

We're going to walk through that, and then we'll talk about the special case of somebody whose immune system is not normal for whatever reason, and then we'll talk about a couple of other things related to that.

For the Pfizer vaccine, it's the same as it has been. It's approved under a EUA for ages five and up. It's two doses in the primary series given three weeks apart. You're considered fully vaccinated for the primary series two weeks after the final dose in the primary series. So a two-dose primary series.

They recommend everyone age 12 and up to get a booster at least five months after the last dose in their primary series.

So you get the first dose, that's day one. Three weeks later, you get dose two. Five months after dose two is when you would get your booster of Pfizer.

Moderna is roughly similar. It's only got a EUA approval for those 18 and up. The primary series is still two doses. They're given four weeks apart instead of three weeks apart.

So first dose, followed by the second dose four weeks later, and you're fully vaccinated after those two doses. And then a booster dose is recommended for those 18 and up who want to get one at least five months after the second shot. The primary series is considered two here, as well, followed by a booster five months later.

Johnson & Johnson. They are still calling the primary series a one-dose primary series. Two weeks after that first dose, you're considered fully vaccinated.

They recommend a booster for everyone who got a primary vaccine with J&J two months after. So that one's two months later to get your booster dose.

When I talk about J&J with people, I really tell them that you can think of it more as those two shots really are the primary series. I don't talk about that second J&J as a booster.

I tell people, hey, this is really the second dose in the primary series, kind of like with the mRNAs. I think it's easier to explain that way and it makes more sense because it's more consistent with the other vaccines, and you really do actually need that second J&J to get the efficacy kind of similar to the two mRNAs.

That is why, in this same guidance, the CDC actually says that the mRNA products are preferred to the J&J because they are more efficacious. That's the general overview and update on kind of normal, healthy people, and that's what they should do.

There's no recommendation yet for an additional booster or a second booster or a fourth shot for normal, healthy people.

There's only a recommendation for the primary series and one booster, so up to three injections at this point for most people, not four injections, for normal, healthy people, right.


So let's move on to the case of those who have abnormal immune systems for whatever reason.

This could be because you're under treatment for cancer or your immune system's not normal because you have either a genetic problem or you're on a medication that lowers your immune system, say something for rheumatoid arthritis or some other chronic illness, something like that, steroids, et cetera.

For you, the situation is a little bit different. They actually consider for both the Pfizer and the Moderna that the primary series is actually three injections. They're not calling that third dose a booster. You need three doses for the primary series.

So the intervals between the first and second doses are the same, as they are for other people for Pfizer and Moderna. It's three weeks between doses one and two for Pfizer, four weeks between doses one and two for Moderna.

The third dose — which a third dose for healthy, normal people is the booster — but for those with immune system problems, the third dose is the third dose in the primary series.

They're saying you really need to have that third dose to be considered fully vaccinated if your immune system is not normal. Get that four weeks after your second dose. So four weeks later for Pfizer, four weeks later for Moderna.

And for J&J, they're saying that two doses are needed. But what they're actually saying is don't get a second J&J. They're saying if you got a first J& J, follow that up with an mRNA product, so Pfizer or Moderna. And that you should get four weeks in between doses one and two, and then two months later, get the third dose of something else.

So for J&J, get one dose of J and J, followed four weeks later by an mRNA product, followed two months later by a third dose of an mRNA. One J&J, two mRNAs for people who got J&J.

They're not recommending for immunocompromised people that they do more than one dose of the J&J. They really would prefer you use mRNAs for all of them, but if you got J&J for the first time, they say, hey, go ahead and get mRNAs for your follow up.

Another question — going back to the sort of normal, healthy folks for boosters — so those particularly who got the J&J as their first two doses. If you want, what you can do is you can switch.

They do recommend for the J&J if you're getting a booster dose, that you try to prefer an mRNA product after the first J&J vaccine.

If you already got two doses of J&J and you want to get boosted with an mRNA product, that is also okay. Just wait at least two months after your second dose of J&J to get your Pfizer or your Moderna, and that should be fine.

Myocarditis Risk + Vaccine Timing

Another interesting update. I know a lot of folks are following the question about the myocarditis risk, pericarditis risk, and especially younger men ages 18 to 39 for the mRNA product, particularly Moderna, but some with Pfizer, as well.

The CDC is actually coming out and saying that it may be fine if you want to wait up to eight weeks between doses one and two, and that seems to significantly reduce the risk of this side effect in that group of individuals. Here's a quick article on it.

If you're a male, 18 to 39, worried about the myocarditis risk from the mRNA products, just space out your doses a bit. Get your first dose. Wait eight weeks instead of three or four for your second dose, and that will bring that myocarditis risk down appreciably.

And remember, one thing to keep in mind. In general, as you get into the older ages — the twenties, thirties, forties, fifties — your risk of getting myocarditis from COVID is higher than getting it from the vaccine.

As you get into the younger age groups under 18, that risk kind of gets a little bit closer in terms of myocarditis from the vaccine versus from the virus. But 18 and up, the twenties, thirties, especially over that, you're starting to get more and more likely to get myocarditis from the illness versus the vaccine.

But in the younger age groups, it's pretty close in terms of the risk. But hey, if we can reduce something that's easy to do and reduce our risk of myocarditis from the vaccine, that's great. So let's do it.

If you're worried about getting vaccinated because of that and you're in that age group, go ahead and just space out to eight weeks. I think that's an easy thing to do, and that way you still can get vaccinated and you can lessen your risk of having that potential side effect, so that's great. I would encourage you to think about that.

Quarantine Isolation Calculator

All right, one more interesting thing. VDH actually put out this really nice quarantine isolation calculator. I wish they had this earlier. It just came out here recently.

You can actually go online there and put in if you've tested positive or if you've been exposed, and you can actually fill out a little information about your exposure or your illness, and it'll tell you what date you should be released from your isolation or your quarantine.

It takes into account your vaccination status, when you're exposed, all that stuff, so it's actually really neat. I would check that out if you're still curious.

I know these questions are continuing to come up over time. Even though a lot of the schools and different places are reducing the contact tracing, it's still helpful for those of us that are trying to make sure you don't want to expose people who are high risk, in particular.

That way you can know when you're safe to be around those people again. If you're worried about giving the illness to someone else, that's a helpful thing to have. So, a lot of great stuff.

New Monoclonal Antibody Treatment

One other thing I wanted to update you guys, there is a new treatment, and it is another monoclonal antibody, which is great. Bebtelovimab is a new treatment for omicron. It's another monoclonal antibody, which is good, and it's an injection given very quickly.

It's not an infusion like some of the other ones, so it's just an injection. You do have to be monitored for an hour afterward, but it's specifically active against omicron, so it's another great option.

HHS and VDH are starting to distribute that to infusion centers and doctors' offices around the state and around the country, so that's another excellent treatment option and it's good.

We need to keep having these come out because, again, we're going to keep having new variants from time to time as things progress and continue on through COVID's time with us, which is probably going to be indefinite at this point.

Masks in Public? 

"I know we're in a lull. My husband and I will still be wearing masks at a conference in Florida in a month. What do you recommend normal people do? Masks or no masks in public?"

I think that for most people — for normal, healthy people — I think it's totally up to you and your comfort level. I continue to think that the data on masks is pretty weak, as it has been all along.

I don't think there's a strong evidence base for masking in public, in public places, like malls and conferences and schools and things like that. I don't think the evidence is very good.

That being said, if you're wearing a well-fitting N95 or KN95, it probably does provide you with some measure of protection. And if you're concerned for whatever reason, I think that's totally fine if you want to wear one and feel free to do it.

It's certainly not going to hurt you. It's certainly not going to hurt you to wear it, and it may provide you some measure of protection.

I think the big thing is I don't want people feeling a false sense of reassurance from masks and putting themselves in higher-risk situations than they otherwise might be comfortable with just because they feel like the mask is making them safer.

I hope that makes sense. So don't rely on the mask as a way to kind of reduce your risk at an event, but if you're going to go to the event anyway and you're a little concerned and you're like, hmm, this might help, go ahead and wear it. I think that's fine.

Quarantine Symptoms

"When using the chart about quarantine, do you use the day you came down with symptoms?"

Yes, correct. You use the day you came down with symptoms, the day you got sick, that is correct. Great.

Boosters After COVID Infection & Vaccination

"I don't know if you mentioned it. Do you recommend boosters if you have had COVID after you've got vaccinated?"

The official CDC recommendation is that you should still get a booster even if you've had COVID five months after your second dose.

I think that's totally fine. I think it's also a reasonable conclusion to draw that if you recently had COVID, that really is like a booster in many ways. If you wanted to wait a bit for a booster, I think that's also completely fine, as well.

And because I think we're going to have more recommendations come out on how frequently we really need to get boosted over the long haul. I think that's going to come out soon.

If you had your two doses and you recently had COVID within the last three to six months, I think it's okay if you want to wait a little bit to get boosted. I think that's reasonable. Again, that's not the official CDC recommendation, but just clinically speaking, I think that's a reasonable thing to do.

It's also completely reasonable to just follow the CDC guideline and get the booster five months after your second dose. I think either of those options is fine, and it's really just based on your comfort level and your risk in terms of getting COVID again at some point.

Second Booster? 

"Is there a second booster out and how do you decide if you should get it?"

No, there's just one booster for folks who are of normal immune system status. So only three doses total, two primaries and a booster for most people. No fourth dose for otherwise normal people.

If you have an immune system problem, then yes, you probably do need a fourth dose, but for everybody else, no, not yet.

Both Shots + COVID Twice = Booster? 

"I know someone that got both shots and has had COVID twice now. Should they get the booster?"

You know, maybe in that case. It may be that they have a particular susceptibility. They may also want to, if they've had both shots and had COVID twice, they may want to actually talk with their doctor and see about checking some antibody levels honestly, because they may not be responding well to the vaccine, and that happens for some people.

If they've gotten the two doses and have had COVID multiple times, they may want to see if they're responding to the vaccine. And if they're not responding well to the vaccine, meaning they're not making good antibodies, then it might be a good thing to talk about them getting Evusheld, and we've talked about that a few times before, which is the pre-exposure prophylaxis antibody.

You can get that every six months. And they may need to use that, rather than the vaccination, because again, if you've gotten COVID twice and you've been vaccinated, that's not really normal. So they shouldn't be getting it that frequently after vaccination. It indicates maybe their immune system isn't quite right.

Fourth Shot if Immunocompromised? 

"When should we get the fourth shot if we are immune compromised?"

Yep, so if you go back up to the second link I posted here, there's a nice little table.

If you are immunocompromised, you should get your fourth dose at least three months after your third dose, if you're immune compromised. So fourth shot three months after your third one. 

When is the next update? 

The next update will be on Wednesday, February 9 at 1:00 pm on our Facebook page. For those without Facebook, we will post our written recap on Thursday. 

Steve E. Bishop, M.D.

As a board-certified internist and concierge doctor in Richmond, VA, Dr. Steven Bishop is passionate about helping his patients improve their lives through better health. He helps healthy adults adjust their lifestyles as they age and helps patients with complex medical diseases manage and improve their health.