by James Lawler, MD, MPH, FIDSA
According to CDC survey data, over 80% of US adults have not received an updated (XBB) COVID-19 vaccine this year. While I believe the proportion of abstainers is likely much smaller in our highly intelligent and educated population of Transmission consumers, I would be willing to bet that many of you reading our newsletter, and many more of your family and friends, have yet to get an updated COVID-19 vaccine. Accordingly, this is my plea to you and your family to get the vaccine now, before the coming winter wave peaks.
I am honestly puzzled at the fact that I would have to argue at all for people to get a safe and effective vaccine against a disease that has killed 1.2 million Americans over the past four years, but I suppose that is a testament to the incredible cacophony of bovine manure around COVID and vaccines in cyberspace. If you want opinions about COVID-19 vaccines, there is no shortage on the internet and social media. Go watch videos from your favorite TikTok influencer, read your crazy aunt’s Facebook feed, or dive into the cesspool of anti-vax vlogs. If you want facts about the COVID vaccine, and why we all should get it, then read on. To make my argument a bit more interesting, and perhaps to give you a helpful counterargument for that stubborn family member, I will frame my facts as responses to the most common rationalizations I hear against receiving an updated COVID vaccine.
The pandemic is over, and COVID is endemic. We can leave mindless arguments about epidemiological semantics for another day. The facts are that COVID remains a major health threat, and we are on the cusp of another large winter wave. in the last respiratory virus season (2022-2023), traditionally defined as October 1st – September 30th, the US experienced 89,000 documented COVID deaths and more than 1 million documented hospitalizations. By contrast, our previously most dangerous endemic respiratory virus, influenza, caused roughly 200,000 hospitalizations and 56,000 deaths that same season, actually a bad year as seasonal flu goes. We have been running about 1,000 COVID deaths per week in the US recently, and that number will inevitably increase if case counts rise. Wastewater testing, our most accurate measure of COVID-19 activity in communities, shows that the current national average wastewater burden of SARS-CoV-2 virus is similar to what we saw in November of 2020, entering one of our worst pandemic waves. Those wastewater levels are on the rise in every region of the US.
I’m young and healthy. COVID is only a threat to old people or people with major health problems. Although the majority of COVID-19 deaths in the US have occurred in persons over the age of 65, roughly one-quarter of those deaths have been in persons 64 and younger. That’s 300,000 deaths. And remember, people between the ages of 1 and 64 yrs in the US just don’t die that often, so relative to expected deaths, that is a huge number. In 2021 (the last year for which we have final published mortality data) COVID was the SECOND LEADING CAUSE OF DEATH in persons 35-44 years of age, behind only unintentional injury. It’s also true that you are likely at higher risk of severe COVID than you think – major risk factors include things like diabetes and lung disease, which are fairly common in adults. Oh, by the way, obesity is one of the strongest risk factors for severe COVID. After Thanksgiving, I am 5’9” and 196 lbs, which in an epidemiologist’s viewpoint puts me precariously close to obesity. Finally, while “smoking the White Owl” (ie getting intubated) or dying are clearly not good, they are not the only outcome to worry about with COVID. For younger people, long-COVID and post-COVID health problems are potentially more concerning. Roughly 1-in-7 Americans reports having had long-COVID, which is most common in middle-aged Americans. Many long-COVID sufferers have debilitating symptoms which can last for years (or perhaps for life). Finally, more and more studies indicate that all COVID infections (not just severe ones) significantly increase the risk of health problems like diabetes and blood clots for a year or more after the acute COVID illness, and COVID survivors have more complaints about and lower scores on objective tests of cognitive dysfunction compared to those who have not had COVID. Avoiding COVID is a very good thing.
I’ve already had COVID. I have “natural” immunity. Congratulations. Surviving a potentially fatal infectious disease has provided your immune system with some protection against future infection. Nevertheless, many studies now show that vaccination in addition to survivor’s immunity consistently provides improved protection against COVID infection, hospitalization, and death compared with survivor’s immunity alone. As with vaccine-imparted immunity, survivor’s immunity wanes over time and becomes less effective as the SARS-CoV-2 virus continues to evolve to escape background population immunity. A more recent boost to your immune response, particularly with an antigen that is somewhat closer to the circulating variants, is the best way to protect yourself and your family.
I hear that the vaccines don’t work. Or…I had the vaccine, and I still got COVID. So, the vaccine doesn’t work. As with most things in life that are not golden retrievers, vaccines aren’t perfect. Just because people still die in automobile accidents while wearing a seatbelt in a car with an airbag does not mean that seatbelts and airbags are ineffective. Studies show that more doses (and more recent doses) of COVID vaccine SIGNIFICANTLY reduce your risk of developing a severe case of COVID, winding up in the hospital, or dying. If you are up-to-date on vaccine, you also appear to have a lower risk of long COVID and other post-COVID health problem. These benefits are true ACROSS ALL AGE GROUPS AND RISK STRATIFICATIONS. Studies designed to accurately assess vaccine impact on COVID transmission also show that vaccination DOES reduce the chance of person-to-person spread of the virus. So, even if you still think that you have some sort of personal superpower protection from COVID health effects, maybe you still would like to avoid giving grandma a fatal case of COVID for Christmas?
I am worried about severe reactions to the vaccine. Or…The risk of dying from the vaccine is higher than the risk from COVID. We have extensive data showing the mRNA vaccines used by the US (Pfizer and Moderna vaccines) have excellent safety profiles, in line with other routine vaccines. Worldwide, well over 2 billion doses of these vaccines have been administered over the past 3 years. The only safety signal that has given any vaccine experts pause is the association with myocarditis (inflammation of the heart) that has been seen in young males. Vaccine-associated myocarditis from the mRNA COVID vaccines has occurred primarily in males aged 16 – 24 after the second dose of vaccine. Even in this highest risk demographic, the risk of myocarditis from COVID (the disease) is considerably higher than the risk from the vaccine. This comparison doesn’t even consider death, hospitalization, long COVID and other harmful consequences of COVID disease. Keep in mind, more than 45,000 adolescents (age 12-17) have been hospitalized for COVID since 2020. Vaccine-associated cases of myocarditis have been generally mild and almost all have resolved without any residual health impact. Importantly, the rate of vaccine-associated myocarditis dropped significantly after a delay was implemented between the first to second dose, from 3-4 weeks to 3 months. Vaccine safety studies have detected very few cases of myocarditis after subsequent (booster) doses.
I already got the vaccine and the booster. I am protected. Completing the primary series and receiving one booster of COVID vaccine is a good start to protection against COVID, but it is not sufficient. Unlike some infectious diseases, immunity against human coronavirus infections is not life-long. It fades over time. You can read hundreds of papers and listen to hours of lectures from immunologists explaining why. For expedience, I will summarize here: we have no idea. Immunity gained from the SARS-Cov-2 (COVID) vaccines is no different – protection decreases over time. In addition to degrading over time, our immunity also diminishes as the virus continues to evolve away from the strain we were vaccinated against. If you received a booster in late 2021 or early 2022, you received a vaccine based upon the original Wuhan variant of the virus. The current circulating variants look quite different to the antibodies and T-cell receptors our immune system uses to fight them off. The bi-valent boosters that were given in the latter part of 2022 until this past September also are antigenically very different from today’s variants. The new XBB-variant vaccines are closer to most of variants circulating now, but the virus is continuing to evolve and trying to outrun immunity. Studies show that time from last vaccination makes a big difference in the likelihood of severe COVID. Other studies show that antibody responses are stronger when you have a vaccine that is more closely matched to the circulating strain. The bottom line is that if you have not been vaccinated recently (within the last 6 months) and you have not been vaccinated with the most recent variant flavor of vaccine, you are at higher risk for developing severe COVID infection, and probably also acquiring long COVID and spreading COVID infection.
I felt terrible after my last COVID vaccine. I can’t afford (or I don’t want) to miss work or be laid up for a day. Fevers, body aches, flu-like symptoms, or localized soreness are common side effects from the mRNA vaccines. And, yes, they can be quite bothersome. The good news is that these symptoms are benign and resolve quickly in the vast majority of vaccine recipients. That seems like a small price to pay to avoid COVID, which clearly has caused many more days of missed work and debilitation. If you are predisposed to side effects from the vaccine, you should consider over-the-counter medicines such as Motrin or Tylenol, which can often prevent or lessen these symptoms. Finally, if you have had a bad experience with a prior mRNA vaccine (Pfizer or Moderna), then you can take the Novavax vaccine. Novavax is a traditional protein + adjuvant formulation that is also based off of the XBB variant, provides excellent immune protection in clinical trials, and appears to have a lower rate of systemic symptoms than the mRNA vaccines. As a personal anecdote, I received the Novavax vaccine for my last booster this fall, and I had no noticeable side effects.
I will conclude my argument by stating that the decision to get the updated COVID vaccine is a low-risk, high-reward proposition. The vaccines are quite safe and present negligible personal hazard to long-term health, while they very effectively reduce the risk of severe COVID and long-term COVID after-effects. They also reduce the chances of spreading COVID within a population. A household that is fully up-to-date on vaccines is much less likely to encounter COVID infection than a household that is not. My colleagues and I are seeing more cases of COVID in the hospital now than we have in almost a year. That number is likely going to continue to climb. All the patients I have seen recently are either unvaccinated or not up-to-date on vaccine. So, do yourself, your family, and your community a favor. GO GET YOUR COVID BOOSTER TODAY. Oh, and while you’re at it, get your influenza vaccine and (if you qualify) your RSV vaccine as well.
James Lawler, MD, MPH, FIDSA
Global Center for Health Security
University of Nebraska Medical Center