Questions Surrounding Future COVID Vaccinations

The Pandemic is now the endemic

I think it’s possible to categorize the diverse COVID vaccine positions of most people into three categories. There are those highly willing to take the vaccine over and over, following recommendations from the CDC and other government Public Health authorities. There is a middle ground comprised of people who willingly took an initial course of vaccine, and may or may not have subsequently contracted COVID, and are now skeptical of any proven need for average risk people to take further doses— at least at this time. Then there are the folks who for various reasons chose never to take the vaccine. Several surveys now indicate that nearly all people in the unvaccinated group have had COVID at least once, if not repeatedly; and the incidence of infection over the last 3 years is not greatly different in the vaccinated group. The vaccines made a tremendous impact on reduction of critical disease and death in high risk individuals and saved many lives—that is a fact. We know from multiple vaccine efficacy studies that at this point in the Pandemic, the moderate protective effect of further booster doses against infection wears off very quickly, and even the increased protective effect against severe disease has very substantially waned after four months. Many people are wondering whether they should take another booster dose now if they took the bivalent booster in September or October. It is not surprising that people are questioning this, since the message from the CDC over the winter months stressed the quickly waning efficacy of boosters, and the very clear pathway to yearly COVID shots in the fall. The CDC has suggested that they will be recommending yearly COVID shots for essentially all adults. They have acknowledged that the impact on hospitalization and death for the healthy 18-50 yo group would be extremely minimal, but yearly shots would lead to a decrease in medical service utilization. Against this background it was a complete surprise to see the WHO advisory group on immunization practices (SAGE) state this week that they do not see the need for any further booster doses for almost all healthy normal adults, and they do not currently foresee the need for yearly booster doses either. The WHO of course, excluded from this recommendation the elderly and significantly immune-compromised, who they say will need continued vaccine updates at least yearly, and suggest that vaccination efforts be directed toward this group. Going even further, the WHO SAGE advisors said they do not currently see a pressing need for further booster vaccinations of normal healthy children, and indicating they believe vaccination efforts in children should prioritize diseases with greater morbidity, depending on specific country conditions. Heads must be exploding at Moderna, Pfizer and the CDC.

If the WHO adopts the recommendations of their SAGE vaccine experts as official policy, then it looks like we will have a very serious divergence of recommendations between the CDC and WHO. Can you imagine that, different opinions on what the Science tells us? My interpretation on one particular issue of vaccination has been clearly stated for quite a while. My opinion for over a year has been that in normal, healthy teenage boys the risk of myocarditis outweighs the benefit from the vaccine. Those teenagers have virtually all had COVID. Data collected in the pre-Omicron era is frequently cited to prove that the risk of COVID induced myocarditis and hospitalization outweighs the risk of vaccine induced myocarditis. Since Omicron took the stage 15 months ago two important things have happened: virtually everyone in the teenage group has been infected, with the development of natural immunity, and the virus is now significantly less virulent, compared to prior variants. The incidence of critical disease, and particularly myocarditis, diminished very significantly in the Omicron era (even in unvaccinated people), but the incidence of vaccine induced myocarditis obviously has not. In a CDC update from June of 2022, on the incidence of reported myocarditis in the 5-17 yo age group with the Pfizer vaccine, the data are presented as an aggregate of all three shots, when obviously the second shot is of greatest concern. Using early data from the first year of vaccine distribution to children, CDC scientists calculated a rough estimate of 66 cases of myocarditis/ million second doses of Pfizer vaccine when given to the highest risk group (boys 12-17 yo). They estimated the vaccine would prevent 215 COVID hospitalizations, 70 ICU admissions and 2 deaths. Recognize that 90% of children with vaccine induced myocarditis (and pericarditis) are admitted to the hospital, so it would be logical to subtract those 60 cases from the 215 COVID hospitalizations.

Update on myocarditis following mRNA COVID-19 vaccination Advisory Committee on Immunization Practices. June 23, 2022.

Other studies have demonstrated an even higher risk with Moderna’s vaccine— not surprising given its higher Spike RNA content. Substantial protection from severe disease is known to accrue from a single dose of mRNA vaccine—would it not have been prudent back in 2022 (or even 2021) to recommend a single shot for this demographic, and doubly true now that the risk of myocarditis and hospitalization from any COVID cause is so dramatically lower than it was even a year ago? Although this complication is very rarely fatal, almost every child with recognized vaccine myocarditis continues to be admitted to the hospital. A number of European nations have recognized this, and have not offered COVID vaccination to this healthy group for quite some time. I also have not been convinced by any data that healthy young children who have previously had COVID are benefited by vaccination, but the CDC continues to ignore the significance of prior infection in a risk benefit analysis for very low risk groups.

Since a number of people have recently queried me, I will quickly summarize my current view of boosters. If you had three doses of vaccine in the past, you only need to take a booster now if you are: elderly (over 70), have very significant immune suppression, or have a serious medical condition which is recognized as putting you in a high risk group for critical disease—and it has been more than 6 months since you either had COVID or your last shot of vaccine. Everyone else should wait until we see what transpires with the the course of the Pandemic (now rebranded as the Endemic), and sit back while the WHO and CDC duke it out.

Let’s turn now to a development on the variant front. There is a new Omicron family variant which is making a move to challenge XBB.1.5 and that is XBB.1.16. This variant was first detected in late January and is rapidly increasing in some locations. India is seeing a significant increase in cases and some increase in hospitalizations. Cases and test percent positivity have increased 3 fold in multiple Indian states over the last 2 weeks, reaching 13% in Delhi, where XBB.1.16 is now 48% of viral sequences. This is alarming enough to the Indian government that they have ordered hospital preparedness drills around the country. This variant has been detected at some level now in 22 countries. While overall world COVID cases and deaths continue to decline, they are increasing in the Eastern Mediterranean and Middle East, and it is thought XBB.1.16 may be driving those increases. There is nothing unexpected about new COVID variants arising periodically, and so far there is no evidence this is a more dangerous version of the virus—but it does bear watching. Chances are good even if this variant ends up infecting a lot of people, that it will not cause a very significant increase in severe disease and hospitalization. It may even infect people recovered from prior XBB.1.5 infection, not because of any dramatic immune escape potential, but simply because of the typical rapid waning of immunity from infection—the protection from severe disease should still be strong in otherwise healthy people.

Thats the short update for this week. Sorry for the lack of graphics, but the Tech Department got wind of Elon Musk’s interest in purchasing the platform from me and they are feverishly posting for jobs on LinkedIn. Spring is breaking out all over, except in the high Rocky Mountains where so far Winter has kept its grip. Please forward these Infectious Disease updates to anyone you feel would be interested. Enjoy your religious holiday season.