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Steve E. Bishop, M.D.

By: Steve E. Bishop, M.D. on August 19th, 2021

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COVID-19 Update 8/19: Immunocompromised Shots, Delta Transmission, Boosters for All, and More

COVID-19 | Facebook Live Recap

On this week's COVID-19 Update, Dr. Steven Bishop discussed the recent recommendations for immunocompromised individuals to get an additional shot of Pfizer or Moderna, the transmission of the Delta variant, when the FDA might fully approve the vaccine, if everyone will eventually be advised to get a booster shot, and more. 

Watch the video below or read on for a full recap. 

Additional Shot for Immunocompromised 

First things first. Everyone's probably seen in the news last week and this week that — if you are someone who has an immune system problem, you're immunocompromised, you've had an organ transplant, you have cancer, you're on drugs that suppress your immune system — then you should go ahead and strongly consider, and it's our general recommendation, that you follow their guidelines.

Get a booster shot, a third dose of one of the vaccines, either Pfizer or Moderna, either one is fine. You can stick with the one that you got before, or you can switch if you want to switch.

I know there have been lots of questions about that. Can I switch? Should I switch? I think it's up to you and your physician.

I think either one is going to give you added protection based on what you've got now. I think the data's pretty clear that at six months out, if you fall into those immunocompromised categories, then your protection is really waning off. And I've seen that clinically as well. A lot of my patients who fit in those categories, where we have to check their antibody levels for various reasons, they've been pretty low.

So I think getting a booster does make a lot of sense for them. And probably if you're in that category, it's going to make good sense for you. Again, both of them are fine. You know, the Moderna may give you a little bit more protection versus the Pfizer.

That being said, for most people, I think it's fine just to stick with the one you got before and get the third dose. That way you're not worried about mixing and matching side effect profiles and things of that nature.

But talk to your doctor if you have questions and see what they recommend on that. I imagine over the next couple of months, we're going to be discussing third doses and boosters for more and more people, especially as we continue to have transmission of Delta variant and whatever variants come after that.

The good news about the protection, even though it does seem to wane at the six-month mark in terms of transmission and infection, it seems to be staying pretty strong for preventing hospitalizations, for preventing fatalities from COVID.

So if you can't get a booster right away, don't want to get a booster right away. I think that's okay. If you want to just get your antibodies checked, if you want to talk to your doctor, there's time for that. You don't have to rush if you're feeling a little bit unsure, but I wouldn't wait too long, especially if you fall into one of those immuno-compromised categories.

I would go ahead and reach out, get those questions answered and go ahead and get those boosters. Because I think eventually we're going to see that the protection is going to wane to the point where it may not prevent hospitalizations or fatalities in people with those immune system problems.

We haven't seen that in the data yet for otherwise healthy people. But time will tell on that. And I imagine more and more people will get into that need-a-booster category. We'll see what comes to that over the next few months.

Delta Transmission

The reason for all of this is because with Delta variant is really ramping up the transmission, and the spread is really phenomenal. I was just talking to someone yesterday. We both know more people with COVID now than we've known altogether in the last 18 months. So the spread is pretty significant out there.

The hospitalizations have started to tick up as well over the last week or so. Thankfully for probably a whole host of reasons, the death rates have stayed very low, which is good, but it is starting to present a strain on our hospital resources in different areas, not as bad here in Virginia as other places, but cases are definitely up across the board.

And another thing to keep in mind is I think the numbers of COVID cases are actually quite a bit higher than what we're seeing even reported out at the health department. Because COVID tests are now available over the counter and you can get them without a prescription, just walk up to the CVS and get a test. And so a lot more people are testing at home and not all those test results are getting reported to the health department, et cetera.

I think there are probably a lot more active cases out there than we even know about. Please, if you haven't gotten vaccinated yet and you're on the fence, please really consider doing it, if it's available to you. Especially if you're about 30 years old and most definitely if you're above 50 years old.

And anyone who has any kind of medical problem, please consider going ahead and getting vaccinated now. If you haven't done it yet, now is the time.

Changing Behaviors?

So that's kind of where we are with Delta. And that brings up another question related to...should we be changing any of our behaviors now, given that the Delta spread is so high and the transmission rate seems to be kind of getting up there, even amongst the vaccinated people?

And I think that question really is going to come down to who you're interacting with. For the vaccinated person, if you're not an immunocompromised person, you're an otherwise mostly healthy person, you've been vaccinated, I don't think there's anything specific you need to change necessarily about your interaction behavior, unless you are going to be around other people that are still high risk, meaning they're immunocompromised and haven't had a booster dose or there's someone who hasn't been vaccinated.

If you are going to be around more people who aren't vaccinated, just know that there is a risk. You could transmit to them. You could be asymptomatic. You could transmit to them and they could get sick. That's definitely a risk.

The unvaccinated person should know that that's a risk that they're taking at this point. I think that's pretty apparent for most people, but it might be good just to kind of make that plain to folks.

And if you're somebody who is in regular contact with an immunocompromised person, I might start restricting contact with that person until they get a booster dose. Just for their safety, because again, you could transmit to them unknowingly. 

When will FDA fully approve the vaccines? 

"When will the FDA fully approve the vaccine? It seems the recommendation for a third shot plays into the anti-vaccine people's complaint that the vaccine is not reliable or it doesn't work."

Yeah, I suspect that the FDA is going to probably approve at least the Pfizer vaccine in the next few weeks. And then probably the Moderna one will get proved shortly after that.

I understand what you're saying there, but these things just do take time. And unfortunately, we're seeing that folks just need the boosters before we've had enough time to completely vet everything. And that's why it's still under this emergency use authorization.

I will say just to reassure people again, 165 million Americans and hundreds of millions of people around the world have gotten these vaccines at this point. So I do think they are generally safe for the vast majority of people, especially adults. I think they're safe. There are no significant signals of harm.

There are certain subcategories, right? Where there's a little bit more risk of side effects for certain of the vaccines, right? Some people are having trouble with blood clots with the J&J vaccine. Some younger men are having an increased risk of myocarditis with the mRNA vaccines.

But that being said, the overall risk of getting a vaccine pales in comparison with the risk of doing poorly with COVID, even for healthy people who don't have lots of trouble.

The problem is that most people in the U.S. are vastly underestimating their risk of not doing well with COVID. The biggest risk is having metabolic syndrome or metabolic disease. And about 90% of Americans have some element of metabolic syndrome, meaning they're not completely healthy.

I think a lot of people are underestimating their risk profile when it comes to COVID. They are overestimating the chances of doing well with COVID and overestimating their risk of a bad effect from the vaccine.

I think most people just need a little bit of a reality check that, just because you're 32 and you think you're healthy, that does not mean necessarily that you're going to do well with COVID because you may actually not be as healthy as you think you are.

Vaccines vs. Delta

"The news alluded that the vaccines are not standing up to Delta. What are you seeing in regards to this?"

Yes, that's true. The vaccines are not standing up to the Delta variant in terms of transmission.

The virus still appears to be able to transmit, to infect people with the vaccine. Which I'm not totally surprised about.

I think we talked about this a little bit, one other week, but we're giving an injectable vaccine, which is going to do really well at producing blood antibodies that are going to prevent you from having a bad outcome from the illness in terms of being in the hospital, dying, getting pneumonia, that sort of thing.

But it might not prevent transmission because it doesn't generate lots of these mucosal or surface antibodies. They're called IgA antibodies. Injected vaccines don't do that well. So I'm not totally surprised that we're still seeing transmission.

The important thing about the vaccines at this point is, even though there's more transmission and the vaccines aren't doing a great job of preventing transmission, that they still are protecting people pretty significantly.

And I think the news probably is a little overblowing it a little bit. It's not like these vaccines do nothing to prevent transmission, right? The efficacy has declined since February and March, but it's not zero. So you still have about a 50% chance for Pfizer and a 70-ish percent chance with Moderna of not getting infected at all.

There's still significant protection there. It's just as good or better than a flu vaccine in most years in that regard. And the same in terms of hospitalizations and deaths.

So it does get a little confusing, because there's a lot of numbers being thrown around all the time. I understand why this is confusing.

Boosters Coming in September

"My understanding is boosters will be available to all in September that either Pfizer or Moderna, eight months after their second dose."

Yeah, that's what's been announced. It hasn't happened yet. But that's been announced as the intention. We'll have to see. It has to go through all the data review, etc, that the FDA process and the CDC process has to complete before they can actually make that official recommendation. That's just sort of a, hey, this is the date we're targeting for booster availability.

Boosters for J&J

"Is there any expectation on when we might have any guidance or approval for additional boosters of some sort for people that got J&J?"

Yeah. Great question. I hope really soon. Because I think that's a really big open question for a lot of people. I'm really hoping we're going to hear something in the next couple of weeks.

I think the FDA and CDC really need to answer this question, very soon. My belief is they're going to say get the booster. But it may be with a second dose of J&J, and they may adhere to that. We'll have to see what they end up saying about that. Again, it's probably going to have to wait for the data review, which probably won't be until September.

What is considered immunocompromised?

"I keep missing what is considered immunocompromised? Do you mind repeating that list?"

Yeah, it's a fairly extensive list that the FDA put out, but basically:

  • If you are a cancer patient under current or recent treatment.
  • If you've had a bone marrow transplant.
  • If you're on immunosuppressive drugs. Any kind of biologic medicine for lupus, for rheumatoid arthritis, for inflammatory bowel syndrome, anything like that would qualify as someone being immunocompromised.
  • If you have a specific condition that is sort of an immune system deficiency, Untreated HIV is on that list too.
  • And any other medical illness where your physician just thinks your immune system is not functioning like normal.

So it's kind of a big list, but only about 3% to 5% of the population probably fits into one of those categories. And if you're not sure, definitely ask your doctor if you fit in the category.

COVID Risk for Kids 11 & Under

"Do we know anything new about the risk faced by kids zero to 11?"

I haven't seen anything new in general, other than there's been a lot more transmission in that age range the last few weeks.

That's been a little bit of a messy thing to tease out because for whatever reason, the RSV, or the respiratory syncytial virus, season moved. Normally it's sort of January, February-ish, which is a normal season for RSV for little kids.

But that's shifted to the summer. Who knows? We could talk all day about why that happened. But nobody knows why. So we were having sort of this big uptake of RSV at the same time we're having a big uptake of COVID.

Those two things together are posing a pretty big risk, especially for really young kids and kids who are preemies, young babies, especially. That's definitely a big risk issue going on right now. I think the numbers are holding pretty steady in terms of the vast majority of kids are doing very well with the virus when they do get it. The younger they are, for the most part, the fewer symptoms they seem to have. Not all the time, of course. But that's the vast majority.

Will Everyone Need a Booster?

"Do you think everyone eventually will need a booster?"

I think eventually they will recommend that most people get a booster at some point. And my suspicion is that this is going to turn into an annual thing, sort of like the flu shot. That's my long-term guess on this.

We will see, but that's probably what's going to happen. Which kind of gets into the fact that I don't think this is going to go away ever. I think the virus is going to become what's called endemic. I think it already really has become that.

And I think it's just going to become part of our normal respiratory viruses that we're going to have to deal with on an ongoing basis. And the goal is to sort of make it as innocuous as we can, realizing that we probably can't eradicate it.

We've only ever eradicated one illness from the planet and that was smallpox. And so I think COVID is going to wind up being in that same category. We're not going to be able to get rid of it completely, unfortunately.

Flu Shots This Year?

"Since you mentioned the flu shot, is there a certain time you'd recommend getting that vaccine this year? I heard the flu season may be worse."

Yeah, so I generally recommend that people get the flu shot in late September, early October to maximize the immunity profile and the length of time that you're immune. I think getting it earlier than that, the immunity starts to wane toward the end of the flu season and you might get it.

So I generally recommend again, late September, early October. I think that's what we're planning at our offices for flu vaccine. But I would wait a few more weeks to do that unless you are a very high-risk person for flu, and then you should go ahead and do it, you know, early September.

But I think most people should probably wait until the end of September, early October for that.

And there's, yeah, lots of speculation about the flu season. I don't know what will happen with it. We were all surprised last year that the flu was so mild. We saw very few to no flu cases. So I don't know if we'll see a repeat of that this year or not. It's impossible to say at this point, so.

Changes in Mask Recommendations

"Are you all recommending any changes in mask wearing right now? Or changes in outdoor activities?"

We at PartnerMD have changed back to everyone wearing masks in the office at all times, even for patients who were vaccinated. We were allowing a little bit of leeway with patients in the exam rooms, but we have gone back to all masks all the time for everybody, regardless of vaccination status in enclosed spaces.

But otherwise, our general recommendation for masks and for activities is to follow the guidance of your local health department. And we haven't made any other specific recommendations other than that.

Activity After Vaccination

"Due to diabetes, my doctor has highly suggested that I get the vaccine. I have a two-month-old granddaughter. I heard that when you're vaccinated that there is shedding of the virus, should I be concerned about being around my grandkids?"

Let me reassure you. With the vaccines, the Moderna and the Pfizer vaccines, in particular, you cannot shed the virus. You do not shed the virus at all. You may shed some viral proteins, but those are non-infectious.

The way these vaccines work is that they trick your body into making a specific viral protein, but it does not actually represent a complete viral particle that can infect someone else.

You are not infected with the virus at any point. You just have a viral protein that's being synthesized in your body. It's not actually the COVID virus in the vaccine or in your body, and you can't transmit it to anybody else. There is no danger of that at all.

So please do, if your doctor has recommended, go ahead and get the vaccine and then feel reassured that you're not going to present any danger to anyone else.

When is the next update?

Our next update will be Wednesday, August 25th at 1:00 p.m. live on our Facebook page.  If you can't make it to the live session, we will post another full blog recap Thursday morning.