Coronavirus update – boosters, current outbreaks, what’s with delta, breakthru infections, the falacy of antibody studies, final comment

After almost 6 months I’m back. I finally got fed up (again!) with all the bad information and misunderstandings. Too many questions, too few answers.

Here is the update as of today.

Boosters

These are the important points:

1. There is absolutely no evidence that a booster, or third shot, of the original Pfizer or Moderna vaccines will provide any greater protection than the original series of two shots already conveys.
2. The current idea of a booster against COVID-19 falls in the pretty good idea category. At present it appears to be based on antibody testing studies. These studies show lessening antibodies in the blood after vaccination. However many vaccines continue to provide excellent protection against illness when no antibodies can be detected in the blood. Several examples include the hepatitis A and B vaccines as well as the new shingles vaccine, Shingrix. It makes sense that caution should be exercised when basing these kinds of recommendations on antibody testing alone.
3. Pfizer has talked about a booster against some of the new strains, but has yet to commit to a timeline for delivery or even a booster protocol. (Does one need one or two shots as a booster? Again there is no evidence on which to make a decision.)
4. From a practical, disease prevention standpoint (despite people quoting results from scientifically poor studies), the Pfizer and Moderna vaccines still provide outstanding protection (98%) against the first few strains of the SARS-CoV2 infection almost a year out from vaccination.
5. The best information shows that those vaccines protection against the new delta strain has waned to about 75-80%. That means they prevent illness from the delta variant 75-80% of the time. That is still outstanding and much better than the J&J vaccine ever was. Also evidence across the world, where those two vaccines have been administered, show continued superb reductions in hospitalizations and death after these vaccines have been administered, regardless of breakthru infections. Despite more vaccinated people getting delta variant illness, they rarely need hospitalization and even more rarely die from it.
6. The first people recommended to get a booster are those who have some immunologic deficiency due to a disease state or due to ongoing medications that significantly impact their immune system. Again there is no data that a booster will help them in any way. There is a practical and reasonable criticism that these people will derive no benefit from a third shot. That is that they did not respond to the first series. Since they did not respond to the first series, where is the evidence that they will respond to a third one given 6-8 months later? Unfortunately there is none.
7. It makes sense to support a booster of the original series IF there is evidence that shows benefit. There is none at this time. If it surfaces, I will change my stance.
8. If Pfizer or Moderna come out with a newly formulated vaccine against the newer strains, then it would make sense to support a new booster regiment. But again this would require a different formulation of the vaccine from the original ones. Until these newly formulated vaccines are available and evidence shows additional benefit, I will have to reserve judgment.
9. The good news is that it is clearly safe to get a third shot of the original Pfizer or Moderna series. In that regard I do not think the recommendation to get a booster will be personally harmful. But to reiterate, the evidence supporting the need and benefit is just not there.

Current outbreaks

States that were mostly dismissive about mask use and social distancing are those closest to filling up their ICU capacity. Those include Alabama, Georgia, Texas, Florida, and Arkansas as of this week.

In Colorado there are several interesting statistics.

1. Since school has resumed, the largest group experiencing increasing illness are those 6-16 years of age. Despite this increase in that age group, there has not been a significant rise in hospitalizations for them. This is not unexpected as all previous literature and experience has shown that this age group has a very low risk of needing hospitalization or developing severe complications. However this group of individuals represent a large pool for potentially conveying this illness to more vulnerable adults. Although there are reports of severe complications, they are still rare.
2. 90+% of hospitalizations in Colorado over the last 6 months are from those previously unvaccinated.
3. The remaining 10% or less are almost exclusively those with immunologic problems (who we know did not respond to the initial vaccine series) or the very elderly in nursing home environments.

What is so special about the delta variant of the SARS-CoV2 virus?

There have been many mutations of this virus since it evolved.

Many have been identified and followed, but none have spread through the population since the first one like the delta variant.

This appears to be due to the simple fact that it replicates faster or more efficiently that the other strains. Early in the spread of the delta variant the CDC noted that people infected with the delta variant had 4-6 times more virus in their nose and throat than with previous strains. The result is that it is much more contagious compared to other strains.

Interestingly it is NOT more virulent. That means that it does not cause more severe disease or is more likely to kill people. It is no more deadly that previous strains. It is just much easier to catch from some random passerby.

As of several weeks ago, 83% of US infections were the delta variant. The vast majority of those getting COVID-19 from the delta variant were those who were previously unvaccinated and not been previously ill with COVID-19 (and hence immune).

What is a “breakthru infection”?

A breakthru infection is getting COVID-19 after being previously vaccinated.

In the last month it means a previously vaccinated person getting a delta variant infection.

Based on the most believable data I have seen and read from reputable sources, the Pfizer and Moderna vaccines still prevent 75-80% of delta variant infections.

Many studies focus on the increased frequency of infections in those vaccinated. They do not look further to answer the question, “What kind of illness do these people get?”. Those studies that looked further show that those who become ill with a breakthru infection very infrequently needed hospitalization and extremely rarely died from it.

Anecdotally, we have seen now 12 people who have gotten sick with positive PCR tests after vaccination. None of them became significantly ill to even consider the need for hospitalization. Our experience as well as the broader literature supports the interpretation that there is still significant partial immunity against the delta variant from previous Pfizer or Moderna vaccination, even it did not prevent the illness completely. These vaccines appears to prevent people from experiencing the severe or life-threatening complications of COVID-19.

So, more vaccinated people are getting ill with COVID-19, but extremely few require hospitalization or die.

The falacy of antibody studies

Antibody testing against an infectious illness can shed light on some very important aspects of our body’s response to an infection.

Whether you have or do not have antibodies detectible in your blood unfortunately does not predict whether you are protected against future illness.

For instance we know that virtually everyone with COVID-19 loses detectible antibodies after 3 months. Does that mean they are susceptible to getting COVID-19 again? The answer is now clearly no. Once you have had COVID-19, you very rarely get COVID-19 again, regardless if you have antibodies detectible in your blood test.

Studies in individuals who had previously been infected with the SARS-CoV2 virus showed that their immune system still mounted a prompt response when re-exposed to the virus 10 months after recovery, well after they had no detectible antibodies in their blood.

What really matters in terms of longer term immunity (whether it is derived from getting the illness or getting vaccinated) is whether your immune system remembers the virus or bacteria. That memory resides in certain cells in your immune system that can immediately stimulate an immune response if you are re-exposed to that virus or bacteria at a later date.

The other practical fact that makes antibody studies of questionable significance when trying to see how long one’s immunity lasts is that virtually no one who has had COVID-19 gets sick with COVID-19 again. This includes all those who got it well over a year ago. And this is even with all the new mutations and variants. Natural immunity to one strain appears to protect again all other strains, regardless if antibodies can be detected in their blood or not.

I have previously quoted the results of a study from the original SARS-CoV1 viral illness from 20+ years ago in southesast Asia. It showed that those who survived the original illness did not for the 7 years of follow up study get the illness again.

Because of the structural similarity of the SARS-Cov1 and the current SARS-CoV2 viruses, I am hopeful that natural immunity from COVID-19 will last at least 7 years. (Again this is an educated guess that will need to be proven.)

There was some evidence of this “cross immunity” to other strains when the second major mutation came out last year as the UK variant. Virtually no one, who had previously had COVID-19, got ill from the new strain. Again it was only those who had not been ill previously that got COVID-19 from the new strain. (This was from the pre-vaccine times.)

At present it appears the best immunity is from having gotten ill with COVID-19. The second best is from the Pfizer or Moderna vaccinations.

Using antibody tests to justify a program of giving booster vaccines just doesn’t make sense. Antibody tests are easier to do than following a population and analyzing post-vaccination infection rates. Making decisions on the most easily available information may not lead to significant benefits unless that information is balanced with other analysis. As best I can surmise from my little outlook, that balanced analysis appears lacking (at least at the level of policy makers).

So what should you do from here?

1. Get vaccinated with the Pfizer or Moderna vaccine. There is a similar vaccine, Novavax, that shows promise, but it is still early in its clinical trial.
2. Should you get a booster? At present I can neither recommend nor advise against a booster. Remember the currently recommended booster is a third shot of the original Pfizer or Moderna series. It is not harmful, but it is completely unproven. The World Health Organization recommends against a booster until evidence shows benefit, as it potentially diverts needed vaccine from other parts of the world. At the present time, I would have to agree with the WHO.
3. If you had previously been vaccinated with the Johnson & Johnson/Jenssen vaccine, then get a Pfizer or Moderna vaccine. As time has shown, the J&J vaccine is even less effective against the newer mutations than it was at first. Even at first many considered it a mediocre vaccine. Time has supported that latter opinion.
4. What if you had proven COVID-19? To be honest all data shows that your immunity is superb against all the newer strains. However the CDC recommends getting vaccinated, even if you had COVID-19. This is an ongoing recommendation based on times a year ago when we did not know how long natural immunity would last. Even though you may not really need the vaccination for health reasons, practically you may need it to go back to school, get certain jobs, or travel abroad. It is safe to get vaccinated after getting the illness. I recommend waiting at least 3 months and preferably 6 months after the illness in order to reduce your risk of vaccine related side effects.
5. Continue to wear a face mask in crowded public spaces and socially distance 6 or more feet.
6. This pandemic is not over, but there is light at the end of this tunnel. And it is not a train coming our way!

Lastly, remember!

Everyone will eventually develop immunity to this virus. That is a simple statement about human biology that will never change, regardless what ideas you hold most dear. It may take 3-5 years for the vast majority of us to become immune, but it will happen. The only question is, “Will you become immune through illness or vaccination?” It is in the end everyone’s choice, but there is now clearly a safe and highly effective vaccine available to all who wish. If one chooses to not pursue vaccination immunity, then you will develop it like most of the country is now.