COVID Transmissions for 9-27-2021

The booster plot thickens

Sep 27, 2021

Greetings from an undisclosed location in my apartment. Welcome to COVID Transmissions.

It has been 6801 days since the first documented human case of COVID-19. In 680, a succession crisis in the Umayyad Caliphate led to the killing of Husayn ibn Ali at the hands of Yazid I’s forces. This event contributes to a civil war that would eventually set the stage for the separation of Sunni and Shia Islam.

In COVID-19, we also have some controversial events to discuss today—the recommendations by various government organizations that the Pfizer mRNA vaccine be given for a third dose in certain individuals. Hopefully this particular controversy will not involve a civil war.

Schedule update: we are in the last week of Jewish autumn holidays. There will be two issues this week—one today, one Thursday. After that we will return to our regular Monday-Wednesday-Friday schedule.

Bolded terms are linked to the running newsletter glossary.

Keep COVID Transmissions growing by sharing it! Share the newsletter, not the virus. I love talking about science and explaining important concepts in human health, but I rely on all of you to grow the audience for this, which you can do by using this button here:

Share COVID Transmissions

Now, let’s talk COVID.

What’s going on with boosters?

When last we discussed boosters, I was relating how the FDA had made a limited recommendation for their use. A lot has happened in the time since.

Specifically, the CDC’s ACIP panel (the Advisory Committee on Immunization Practices) met to elaborate upon the restrictions that the FDA applied to the use of booster doses for the Pfizer vaccine.. That panel, somewhat in alignment with the FDA’s recommendations, called for booster vaccinations in people 65 and older and those at higher risk of serious disease due to underlying medical conditions. The CDC panel did not recommend boosters for those in potentially high-risk living and working conditions.

Instead, CDC director Dr. Rochelle Walensky did that, going a step further than the nonbinding committee recommendation: https://www.nytimes.com/2021/09/24/world/covid-boosters-vaccine-cdc-director.html

So, the recommendation from the CDC as it currently stands is that people over 65, people with underlying medical conditions, and people who work in high-risk jobs or live in high-risk communal living settings, who have been vaccinated with the Pfizer-BioNTech mRNA vaccine (“Comirnaty”)

I’ll be quite honest: I don’t entirely know what to think of all this. I still feel confident that additional boosters are not the best possible move either in a national sense or as a means to get out of the pandemic globally. The gains that they offer in terms of prevention of disease seem to me to be rather limited by comparison to what we might gain from focusing on vaccinating new individuals. That latter initiative is proceeding better than it was a few months ago, both here in the US and elsewhere, and I wonder if we couldn’t be focusing on maximizing that better than we currently are.

That said, however, I have recently heard a couple of arguments that do make me more welcoming to the concept of booster doses for these restricted populations. First, it has been suggested that while adding a third dose may not do much to improve the excellent effectiveness of these vaccine against severe disease, it may do quite a bit to stem transmission of COVID-19 in the community. I don’t believe I’ve seen firm data that say this is what will happen, but from everything we know about how these vaccines work, I think that improving the antibody levels through an additional dose might well serve to help us get SARS-CoV-2 circulation under better control.

That is a speculative point, however. Far more important to me is the clinical evidence from the administration of additional doses, which suggests that the third dose does not pose a substantial risk to people. There are still some rare matters of concern, of course—such as the unusual myocarditis that is sometimes seen in younger patients—but overall it appears that third doses, particularly in the targeted populations here, are not matters for substantial safety concern.

I think at the end of the day it is clear that third doses of the Pfizer vaccine do have a clinical benefit. Just because I question the magnitude of that benefit or its overall worldwide value does not mean that it is not real. At the same time, it is clear that these additional doses do not pose a meaningful additional safety risk in the broader population for which they are being recommended. With these two considerations in mind, I think that it’s reasonable to make such doses available. I’m not sure how firmly I might recommend them—clearly the CDC feels they should be actively encouraged—but I certainly don’t see the harm in such a recommendation when it comes to the individual patients.

At a worldwide level, we could have a conversation here about vaccine doses and supply, but I think unfortunately our ability to distribute vaccines and get people to take those vaccines is lagging behind our ability to produce them. These booster doses, in my opinion, are not at this time going to represent a huge drain on the global supply or meaningfully take doses away from people who might otherwise have become new vaccinees. This might have been different if even more substantial effort had been put in place to vaccinate new patients or to better globally distribute doses, but that isn’t what has happened, for various reasons that I think are both political as well as practical. That’s a fancy way of saying that I don’t think we focused on that strategy because there are people politically opposed to it, and it’s currently too hard to convert them to a way of thinking that helps us better control the pandemic.

Looking at that reality, I don’t think we’re really talking about a zero-sum situation where putting boosters in one patient’s arm takes a dose out of a new patient’s arm. If we’re not in that situation, and there are at least nominal benefits of providing third doses without substantial safety concerns, then I can’t very strenuously object to their having been recommended.

If you’re in one of these indicated populations, have a conversation with your physician about what’s best for you. I’m not going to second-guess the CDC on this—I might on other things, but here, I don’t see a good reason to. When my number comes up, too, I’ll also go in for that third dose.

What am I doing to cope with the pandemic? This:

Waiting for the baby to come

It’s a strange time, with my wife and I being quite certain that our child will arrive “soon,” but with no particular idea of when “soon” is, exactly. We have decided to hurry up, and wait.

You might have some questions or comments! Send them in. As several folks have figured out, you can also email me if you have a comment that you don’t want to share with the whole group.

Join the conversation, and what you say will impact what I talk about in the next issue.

Also, let me know any other thoughts you might have about the newsletter. I’d like to make sure you’re getting what you want out of this.

Viral Transmissions

Discussion about this post