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David Pong, M.D.

By: David Pong, M.D. on November 3rd, 2021

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COVID-19 Update 11/3: Boosters, Pfizer for Kids, Thanksgiving, and More

COVID-19 | Facebook Live Recap

In this week's update, Dr. David Pong fills in for Dr. Bishop and discusses the effectiveness of the boosters, the Pfizer vaccines for kids, what you should think about before Thanksgiving, and more. Watch the video below and read on for the full recap.

Booster Effectiveness

There was a study published about a week ago in The Lancet, which is one of the British journals that's done a really nice job with data this COVID pandemic. They published a study done in Israel.

Now, Israel is interesting because it's a large population that's cared for primarily by one health system. It's a society that strongly supported vaccination and nearly everyone eligible for vaccination has been vaccinated using the Pfizer vaccine. So they did a study looking at one and a half million people — 750,000 of them were people who were vaccinated about five months before the observation window and the other 750,000 were people who had received a third dose in the weeks prior to the observation window.

And then they watched them for several weeks and tried to get a sense of how well the booster protected people against infection compared to folks who had only received two shots.

And it turns out it was very effective — about 90% more effective in preventing hospitalizations or severe disease and about 80% more effective at preventing dying or getting death.

In many of the studies that have been published, we've been looking at effectiveness as rated by antibody levels, and we do that because the higher the circulating neutralizing antibody levels are, the higher the presumed effectiveness is.

There actually has been a study published on that that is a nice confirmation of that again in Nature Medicine. They described a group of folks where they were able to measure levels of neutralizing antibodies and then event rates, people getting sick, people becoming infected, and they were able to show a clear correlation.

So neutralizing antibodies are certainly part of how we determine effectiveness, but it's nice to see in this study in The Lancet that they're actually looking at the outcome that we care about — directly looking at hospitalizations and severe illness.

Clearly boosting is helpful. The recommendation, of course, that comes out of this kind of study is if you are eligible, please get a booster. Remember those over 65 who are more than six months from their second shot, or more than two months after their dose of Johnson and Johnson are eligible for vaccination and that can be done either with a Pfizer or Moderna vaccine.

And then those over 18 who have underlying conditions that put them at higher risk or jobs or living situations that put them at higher risk are all eligible for boosters. Of course, if you have not received your first round of vaccination, please consider doing that.

We're now at a point where about half the world's population has received at least one dose of a vaccine, and we're showing really incredible safety, particularly when you compare it to the risks of getting the disease itself.

Unfortunately, in the same timeframe that we're seeing half the world's population having received a dose, we're crossing another milestone — about 5 million people have died from COVID-19. So a challenging time that way.

Pfizer for Kids

All right, let's move on to the second topic. The CDC did finalize approval to provide a low dose of the Pfizer vaccine to children 5 to 11 years of age. And they based this on both safety and efficacy.

The safety component was a combination of a direct study of children, as well as looking at the really remarkable safety profile of the COVID vaccines in the Pfizer vaccine, in particular in young adults and in older adults after millions and millions of doses.

The study looking at 5 to 11-year-olds shows that the side effects you can anticipate are similar to what we've seen in younger children. You can end up with a sore arm, you can end up with fatigue, low-grade fevers and body aches for a day or two, and then typically that's it and it will go away and leave behind protection.

In adolescents and young adults, there have been cases of myocarditis and pericarditis, and these have been concerning with the mRNA vaccines. They're thankfully rare, something on the order of 2 to 10 per hundred thousand people who get vaccinated, so fairly unusual.

And the great majority of people who this has occurred in have recovered quickly, sometimes a brief hospitalization often with some oral drugs, and then again, seem to go back to normal.

Myocarditis and pericarditis in younger adults is a concerning potential side effect with these vaccines in young adults. It was not seen in the children's studies, but they were smaller numbers and it's certainly possible that we could see some of that, but it would be anticipated that should that occur, the risk of any lasting damage should be low.

Keep in mind that both myocarditis and pericarditis are features of many different viral infections and certainly are much higher risk complications from the virus itself as opposed to what we see with the vaccine.

Staying with that, part of the reason to vaccinate children is looking at what happens to children who get sick. There are complications. While thankfully not a lot of children have been hospitalized or died relative to the number who've been infected, those who get sick have higher complication rates and there is the difficulty with a multi-system inflammatory syndrome where you can have multiple different organ systems involved, and that's been a real challenging problem that sometimes lingers after acute COVID infection in children and in adults.

So preventing that is certainly part of the goal of vaccination. Many of you are parents with young children and many folks of course been clamoring for vaccination in order to get kids back to school, and in order to get kids back to school without having to break for quarantines and isolations as there have been cases in school.

Remember, this is another opportunity to remind everyone about vaccines and their effectiveness. When we talk about 95% effectiveness, it does not mean that 95% of the people who get the vaccine will not get infected.

Effectiveness means that only 5% of the people who get the vaccine will have severe outcomes or significant illness despite being vaccinated. So it's kind of an important thing. Vaccines are not perfect. We don't and should not expect the vaccine to prevent all illnesses, but they have been remarkable in their ability to prevent us from hospitalization or significant illness, ICU time and dying. Really remarkable.

And those effects for the Pfizer vaccine, when a good six months for the Moderna vaccine seemed to have lasted a bit longer, and that is part of the hesitation in opening up the recommended boosting for Moderna, because actually the original vaccine series has been so effective.

Kind of an interesting and fun idea. They are exploring the possibility of an intra-nasal vaccination that would spray a vaccine onto the surface of the nose the way that the actual virus would come into contact with us and be acquired.

And if successful that vaccine should provide antibodies that live in the surface linings and would actually be more effective at preventing acquisition and transmission of the virus, where the vaccines that we inject are primarily working in the deeper tissues preventing deep infections and preventing severe illness. So exciting news about vaccination.

These vaccines, having been approved yesterday, are already being shipped in Virginia. There is some anticipation of some delays in actually getting them into arms. There was an article in the Virginia Mercury just this morning that talked about some supply bottlenecks that are anticipated, but probably over the next few weeks, we should be able to vaccinate everyone who's interested in being vaccinated.

The doses that are being delivered should be adequate, it's really just a matter of getting them into the right distribution facilities.

At PartnerMD we will not be providing pediatric Pfizer doses. Unfortunately, they're still bottling these up in large enough quantities that we just don't have enough 5 to 11-year-old children in the practice to be able to vaccinate here. And we would recommend that you work on getting these at perhaps your local pharmacies. CVS and Walgreens have set up their scheduling at least so that you can schedule doses for young children already and I anticipate you'd be able to get those in the coming week or so.

The last thing that I wanted to talk about was their modeling. There have been a lot of statistical modeling studies done trying to predict what will happen if different interventions happen, and modeling of dosing of the 28 million children ages 5 to 11 with this vaccine projects that we will save 600,000 lives.

So a fairly active value in vaccinating kids. Part of that, of course, is for the kids themselves. Part of that is that vaccination, while it doesn't eliminate acquisition and transmission of the virus, it certainly reduces it a bit and lowers the chance of then another family member who perhaps is more vulnerable to severe illness of becoming infected from a child who was not vaccinated. The vaccination should help in that regard. So 600,000 lives, pretty exciting.

Thanksgiving Plans

All right, the last thing in my prepared notes. Holidays are coming up and at least I've shared with you before in this channel that my family has been a large gathering kind of family for holidays. Particularly for Thanksgiving, we would frequently have 30 or 40 folks in my little house. And it's been a real challenge. We miss that in our family.

And yet like most families, we have a pretty wide array of people in terms of COVID. We have folks as young as one year old and we have some folks in their high 80s in my family. We have folks who are heavily vaccinated and we have folks who've decided that they don't want to vaccinate at all.

We have folks who are really taking the masking and social distancing and hand washing and limiting their group activities quite seriously still, even now. And we have folks who are much less careful with that.

In our family, as we've tried to approach this, part of it is trying to think about who would be in the room if we were to get a big group together and how risky can we anticipate that being for the people who might attend and how to balance that.

I would encourage you to do the same, as you're thinking about your holidays. I would think about who's going to be there. If you have a bunch of young adults, if you have particularly a bunch of vaccinated young adults who don't have underlying health problems, I think you ought to go for it. I mean, the risk is really quite low.

I think the higher the risk or the higher the vulnerability of your population in your family — the more people who have underlying illnesses, immunosuppressive conditions, diabetes, chronic disease, obesity, folks who have active problems that would make them higher risk should they acquire the virus — you might step back a little bit and think about a smaller gathering.

Again, vaccination, I think, really changes the risk calculation. If you have people who are unvaccinated, they are certainly at higher risk of acquiring and getting sicker from the virus. Remember, if you look at the folks hospitalized with COVID-19 right now, 97% of them are folks who are unvaccinated and only 3% are folks who are vaccinated, and most of them have some underlying condition that puts them at higher risk.

The people who are at the highest risk are the unvaccinated if you get groups together. You can look at that and decide, are those people folks who are otherwise at high risk, or are they again young healthy people that you could statistically anyway expect to have a better outcome?

So all of that, if folks are willing to vaccinate before the holidays, I think it's a great idea. And while if you've got the first dose now and if you chose a vaccine that needed two doses, you got a second dose in three weeks, it would still have you well on the way to a lower risk and having a higher level of antibodies.

If you have a group where you're not sure and you wanted to try and lower your risk further, another possibility is testing. Now it's probably going to get a little tight trying to get testing done in facilities like here at PartnerMD, but we only have a certain number of people who can be tested each day. We just run out of capacity. But there are some over-the-counter tests available.

The most commonly available one is called BinaxNOW. It's a test by Abbott. It's a home test. In the pharmacy where I go, recently they were $16 apiece and they would provide a reasonable rapid test.

You swab at home, you test, and 15 to 30 minutes you have a result. If it's positive, it's a true positive. You can believe that it's true and you should assume that you're infectious. Those who were positive or anyone who has symptoms, I think should not be hosting or attending a gathering of other folks.

If you have a negative test, it's not perfect, but if you have a negative test, certainly if you're vaccinated with a negative test, that's very reassuring. If you're not vaccinated but have a negative test, no recent exposures that you know of, and no symptoms, it adds another layer of comfort, another layer of insurance that you're not likely to give the virus away.

That's something to consider, and they're readily available and is a reasonable thing if you wanted to try and test.

Again I would say, if you have symptoms, if you're all set to go to Thanksgiving and you wake up with a sore throat and a fever, you shouldn't go.

And unfortunately, if you happen to be the host, you shouldn't host. The likelihood is pretty high that whatever you have is transmissible and while it may just be a cold, these days we have to at least think about the possibility of COVID.

Finally, some people have the opportunity to do this outdoors, and if you can make that happen, if you have the heaters and the coats and people are willing to spend more of their time outdoors, consider, who knows how the weather will be, that'd be pretty tough to do it today, but it's possible that we'll have a warmer Thanksgiving.

I encourage you, it's hard to give you exact advice about what's right for you, but I encourage you to think about it. And we have a few weeks here where potentially folks could continue to get vaccinated and lower the risk further and I would certainly encourage folks to do that.

Unmasked Choir Concert

"Our church choir wants to do our Christmas concert unmasked. All members are vaccinated, some with boosters, and all are willing to take a COVID test beforehand. Any thoughts?"

Yeah. Well, I think thank goodness a bunch of things. If folks are vaccinated and boosted and are willing to test — if everyone's negative, asymptomatic, and vaccinated — the chance of actually having a spreading event is actually pretty low and I think it's a reasonable thing to consider.

Again, there are things we've talked about in the past that the bigger the space, the more airflow, I think that the lower the risk. I think that it's hard these days to get to zero, right?

What we want is the sense that there isn't risk and we can't get to that, but you're describing a pretty low-risk way to do this.

I think if I was to add one other layer, it would be trying to take what steps are possible to reduce your exposure ahead of the event. I have people come to see me for preoperative exams. They're going to have surgery in two weeks, and one of the last things I always say to them is that your most important job is don't get sick.

Because then you're going to lose your spot in line. They will not do elective surgery on you. And the same thing I would say here is, you're heading into this concert, I think it would make sense for whoever your members are to step back from their other social things. I would not go out as much. I would not get into groups as much. I would try to isolate a bit more as I was heading towards the events, so that my chances of acquiring the virus go down.

I would take seriously masking and the hand washing and the distancing trying to reduce the chance that I'm going to pick it up despite all the other steps I've taken. So I think it's a reasonable thing to consider.

Dr. Bishop's smarter than I am, right? So he may be able to work out the actual numbers statistically, but I would say it's a reasonable approach to do that. Sure.

Flexibility During COVID

I had one other thing that I came across that I thought would be interesting. It's just some ideas about the effectiveness of vaccines. And again, I think Dr. Bishop has talked some about this.

Part of the challenge of all of the questions that have come up during COVID, at least from my point of view, has been that the answers keep changing. Right? And sometimes the questions keep changing. When we first started talking about vaccination, I think we all had this sense that we were going to get some shots and then we weren't going to talk about this anymore.

We certainly didn't expect to be talking about it in November, and I think that was a mistake on people like my part, I sort of believed this notion that vaccination was going to get us out of this.

And I think vaccination is a very, very strong step, it makes it much less likely that the vaccinated person will end up in the hospital dying. It should, at least the early studies are suggesting, it should lower the risk of long COVID.

There's a lot of advantages to vaccination, but what vaccination does not do is provide us with antibodies on the surfaces that can prevent us from acquiring and transmitting the virus. It doesn't do that.

And we know that from some of the more recent studies and some of the observational studies where we can see events that have occurred. But we do know that vaccination is dramatically effective at lowering the chances of getting acutely ill, hospitalized, or dying and should provide benefits against long COVID.

Those are really strong advantages. I know it gets frustrating when we look at some of these things and it feels like the goalposts keep moving, but I guess I encourage flexibility. I encourage us all to kind of think about the big pictures.

This virus is likely to become a thing that we continue to live with. It likely over time will become less dangerous but continue to remain very infectious. We may have vaccinations that would better protect us, such as I described about spraying it in the nose.

Some of the technology that we're learning as we use these mRNA vaccines may allow us to have vaccinations that protect a little better against other Coronaviruses, which is kind of exciting, and possibly even other areas.

There are some silver linings through this, but we are probably going to need to continue to think about masking and washing our hands during the winter months. And we probably should have been doing it before this virus came, but now I think it's sort of in our faces and I think we need to accept that.

I think that taking responsibility for each other is another thing that comes out of this. Part of the reason I am vaccinated is not just for protecting me, but it's for protecting my patients, protecting my coworkers. I encourage folks to think about that as you're also contemplating that we vaccinate the kids. There are some concerns about that, but at the same time, you're protecting the people all around them.

And when you get groups of people where everybody's vaccinated, the chance of someone bringing the virus in and spreading it around goes down significantly.

Pretty high probability that there will need to be some type of boosting periodically. I think we're not out of the woods where this is it, but I also think that if you look at folks who receive their initial series and get a booster that the likelihood is pretty high that the antibodies that we make from these and the immune memory that we create from these vaccines should be durable enough that we probably won't need to be thinking about boosting in the next year or so.

That's my best guess, but I think we're looking at some more durable immunity than that.

When is the next update? 

The next update will be on Wednesday, November 10 at 1:00 pm on our Facebook page. For those without Facebook, we will post our written recap on Thursday morning.