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Opinion The Checkup With Dr. Wen: When will it be time for a second bivalent booster?

A nurse loads a syringe with a coronavirus booster vaccine at a facility near Jackson State University in Jackson, Miss., on Nov. 18. (Rogelio V. Solis/AP)

You’re reading The Checkup With Dr. Wen, a newsletter on how to navigate covid-19 and other public health challenges. Click here to get it in your inbox.

My column this week focused on the ongoing discussion at the Food and Drug Administration about switching the United States to a yearly covid-19 booster schedule. I think such a plan would simplify operations, and a targeted mass vaccination campaign every fall that’s synchronized with the flu vaccine could increase uptake.

But that doesn’t mean everyone needs an annual covid booster. And there might be people who would benefit from a booster more than once a year.

Whether some people should get a second bivalent booster is by far the most-asked question from Checkup readers. Don from Washington wants to know when he and his wife — both cancer patients in their 80s with diabetes, heart disease and other underlying medical conditions — should get another booster. “We got the bivalent vaccine as soon as it became available. Do we need to wait until next fall for another shot?”

Sheryl from Nebraska writes that she and her husband are going on holiday to Europe in April. They are in their 60s and generally healthy, but they want to keep avoiding the coronavirus. “Can we get another booster before we leave?”

And Jane, a 52-year-old from California, says she’s worried because she cares for elderly parents. “Am I eligible to get a second bivalent booster?” she asks.

Let’s start with the question of eligibility: Federal health officials have not yet authorized a second bivalent booster, even for elderly or immunocompromised people. So, technically, no one is eligible for a second bivalent booster.

That said, I can understand why some people are eager to obtain another booster. Those who received the bivalent shot when it first became available in September have already had five months elapse since their last vaccine. The good news is that protection against severe disease is probably still strong, and recent data from the Centers for Disease Control and Prevention confirm that the bivalent booster is effective against the now-dominant XBB.1.5 subvariant.

Leana S. Wen: Should there be an annual coronavirus booster? It depends.

But protection against symptomatic disease has probably started to wane. Individuals who are medically frail and vulnerable to severe illness are understandably concerned about contracting the coronavirus. If another booster dose can temporarily restore some protection, many might opt for that added benefit.

Again, federal health officials have not yet advised the bivalent booster for anyone. Still, I think it’s reasonable for people who are 75 and older and who have severe underlying medical conditions to discuss with their physician about the best way to protect against being hospitalized.

As I have repeatedly emphasized, everyone should have a plan for what happens in the event they contract covid. This is especially important for people who are most vulnerable to severe illness. Now that monoclonal antibodies are no longer authorized for covid, treatment options are more limited.

Find out now whether you are eligible for the antiviral pill, Paxlovid. If not, can you access remdesivir, an injected medication that is also effective in reducing hospitalization?

Some people might still be so vulnerable that, despite these treatments, they still need to reduce their chance of contracting covid. Don and his wife might be in this category. Such individuals could discuss with their physician about getting another booster. Many health-care providers follow federal health guidance to the letter, but some might have more lenient policies that allow customizing to the individual patient.

Sheryl and her husband, on the other hand, are not in this vulnerable category. If they wish to avoid covid during their trip to Europe, they should take other mitigation measures, including wearing a well-fitted, high-quality mask in public indoor spaces.

Jane, too, should not pursue a second booster, but rather use masking and home testing to reduce the chance of spreading the coronavirus to her parents. And she needs to make sure her parents have a plan should they contract covid.

In the meantime, I hope the FDA and CDC will issue official guidance soon to allow a second bivalent booster for vulnerable individuals. These are the people at highest risk for severe outcomes, and allowing them more frequent boosters can offer some added protection and reassurance.

Ask Dr. Wen

Newsletter subscribers are invited to submit questions to Dr. Wen. Not a subscriber yet? Click here to sign up.

“Did I have covid? I am a 74-year-old healthy female and my husband is a 78-year-old healthy male. We are fully vaccinated and boosted. We have visited three grandchildren under the age of 4 (one weekly) within the last month and a half. After two weeks with a dry cough, I suddenly lost my sense of smell and taste. I did an at-home rapid and then a PCR test with negative results. The following week, I still had a cough and reduced small and taste. I thought I might have RSV, so I called my primary care physician who sent me to get an RSV test. During that visit, I tested positive for covid with a rapid test, even after just having a negative PCR three days before. Over the next week, I took two different tests, but they were negative. My husband is four days behind me in symptoms, but he never tested positive. What is my status now? Have I and my husband had covid? Did our fully vaccinated and boosted status have some impact?” — Marsha from Maryland

Given that you had one positive coronavirus test, you probably contracted covid. False positives are rare.

There are a few possibilities that could explain the multiple negative tests. Perhaps your initial symptoms were due to another virus. Your grandchildren, especially if they are in school or day care, are probably exposed to the many respiratory viruses that circulate in the winter. Other viruses can also cause a loss in smell and taste, especially if you have a blocked nose. If so, you probably got covid shortly after catching those illnesses.

Why were subsequent tests negative? Perhaps your body cleared the coronavirus quickly. Tests come back negative when there aren’t high enough levels of virus for them to detect. Some studies suggest that vaccinated individuals can clear the virus faster, which is another benefit of vaccination.

I don’t think a false positive is likely in your case. For others who want to know whether they had covid before, they could take the SARS-CoV-2 nucleocapsid antibody test. Your husband could use that blood test to see if he recovered from covid — though, if it’s positive, you won’t know whether it was a recent infection or he had covid in the past.

“I received the bivalent covid booster in early September. I tested positive for covid in early September, got Paxlovid and seem to be headed for an uneventful recovery. I’m disappointed that I got only three months of protection from the bivalent booster. Why did I get covid at all?” – Peg from New York

A lot of readers have a similar question. Like you, they contracted covid despite receiving the updated booster.

This is to be expected. We need to reset the expectation around the coronavirus vaccines.

When data initially came out about these vaccines in December 2020, they seemed excellent at protecting against infection. That’s no longer the case, especially with the more immune-evasive omicron variant.

The coronavirus vaccines protect well against severe disease. They also reduce the risk of infection for at least a short period. But we cannot expect them to protect against all infection, because they won’t.

One of the challenges in public health is that it’s hard to judge when something works because that means a bad outcome didn’t happen. We don’t know what might have happened if you were not vaccinated or did not receive the updated bivalent booster. Perhaps you would have been more severely ill and hospitalized. The vaccine, and Paxlovid, probably helped you with the uneventful recovery. That’s the key, and it underscores the continuing importance of vaccination and treatment — not to prevent any infection, but to stop most severe illness.

“At 80 years old, I finally got covid at the beginning of January and started Paxlovid immediately. Two days after completing the five-day course, I tested negative. Then I tested positive again with Paxlovid rebound. This time, my mild upper respiratory infections symptoms were worse for more than a week until I tested negative again. I read that when Dr. Fauci got Paxlovid rebound last year, his doctor prescribed a second five-day course of Paxlovid, but the FDA has not changed its recommendation. For us ‘older’ people with less robust immune systems, is it time for the FDA to consider a second dose of Paxlovid, or even allowing a 10-day course?” — Katherine from California

I’m glad that you recovered from your covid infection. As I wrote about before, Paxlovid rebound is annoying, but it isn’t a reason to for eligible patients to avoid the antiviral treatment. Your initial five-day course could have kept your respiratory symptoms from becoming more severe.

At the moment, the FDA does not recommend a second five-day course for rebound symptoms, though this is something that some physicians prescribe for their patients (including, as you noted, for Anthony S. Fauci himself).

The FDA has asked Pfizer to conduct studies on whether this second course of Paxlovid offers clinical benefit. A longer 10-day course is also being considered on the theory that a longer period might be necessary to achieve viral suppression.

The Post has also compiled Q&As from my previous newsletters. You can read them here.

What I’m reading

If someone in your household has the flu, how likely are you to contract it? A new study published in JAMA has some surprising answers. In the 2021-22 season, 50 percent of household contacts with influenza became infected. This was a dramatic increase from influenza seasons before the coronavirus pandemic, when only about 20 percent of household contacts contracted influenza. The authors write that one possible reason is because pandemic mitigation measures reduced the percentage of people with naturally-acquired immunity, making them more susceptible when the precautions were eased.

I was surprised and disappointed by the findings in this JAMA Network Open report. Researchers identified more than 42,000 patients in the Kaiser Permanente network who were immunocompromised. At the time of the study, these patients were supposed to have received four coronavirus vaccine doses, but only 41 percent had. After the CDC recommended a fifth dose, the uptake was even lower; only 0.9 percent followed the CDC guidance. Far more must be done to specifically address vaccine uptake in this vulnerable group.

A report from the National Academies of Sciences, Engineering, and Medicine, produced at the CDC’s request, lays out a vision for a nationwide wastewater surveillance system. The paper proposes the tracking not only of the coronavirus but also other emerging pathogens. I particularly appreciated the focus on international airports as an ideal place to identify new variants and viruses.

Coronavirus: What you need to know

Where do things stand? See the latest covid numbers in the U.S. and across the world. In the U.S., pandemic trends have shifted and now White people are more likely to die from covid than Black people.

The state of public health: Conservative and libertarian forces have defanged much of the nation’s public health system through legislation and litigation as the world staggers into the fourth year of covid.

Grief and the pandemic: A Washington Post reporter covered the coronavirus — and then endured the death of her mother from covid-19. She offers a window into grief and resilience.

Would we shut down again? What will the United States do the next time a deadly virus comes knocking on the door?

Vaccines: The CDC recommends that everyone age 5 and older get an updated covid booster shot. New federal data shows adults who received the updated shots cut their risk of being hospitalized with covid-19 by 50 percent. Here’s guidance on when you should get the omicron booster and how vaccine efficacy could be affected by your prior infections.

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