Choosing a COVID-19 vaccine booster

[sevenperforce]

The FDA has now officially expanded the EUA for the three COVID-19 vaccines currently available in the United States to allow boosters regardless of what initial vaccine a person formerly received. In addition, the FDA has approved individuals to "mix and match" boosters, so that a person who received the J&J vaccine could get a Moderna booster or someone who received the Pfizer vaccine could get a J&J booster. This raises the question -- what's the best booster to get?

There's a recent study out of the NIH which suggests that if you got the J&J single-shot vaccine, you will do better with an mRNA booster than with another J&J shot. However, it didn't address what happens if you take the J&J booster after the mRNA vaccine, and it also used only a single-date antibody test so it's hard to know for sure that the J&J booster didn't catch up with or exceed the mRNA booster levels.

Any ideas? I got Moderna...would I be better off with J&J?

[Guest The Doodling Astronaut]

I would stick with a Moderna vaccine booster, that's my personal opinion though. It's hard to discuss my thoughts on what you should get without feeling i'm going to break the political rule. But I'll say that if you got Moderna I would go with Moderna booster. For me, I got Pfizer, so I would probably go get Pfizer.

 

[JoeSchmuckatelli]

I have read similar articles - I got pfeizer so if I were to get a booster I'd pick one of the other two. 

 

However in my equation, there is also the fact that I got covid last January (still can't smell, dadgumit) - so I feel like it's not a priority for me to get a booster any time soon.  

(Presumes I have antibodies from surviving the disease) 

Still - from what I have read mix and match provides a better boost than sticking with the original 

Oh - and if anyone reading this is one of the idjits who does not want the vaccine... Trust me you DO NOT want the disease... Even a mild case has long after effects that are not fun

Edited October 21, 2021 by JoeSchmuckatelli

[sevenperforce]

44 minutes ago, The Doodling Astronaut said:

I would stick with a Moderna vaccine booster, that's my personal opinion though. It's hard to discuss my thoughts on what you should get without feeling i'm going to break the political rule. But I'll say that if you got Moderna I would go with Moderna booster. For me, I got Pfizer, so I would probably go get Pfizer.

 

I don’t *think* this gets political.

There are a few differences between the Pfizer and the Moderna. Moderna uses 100 micrograms of active ingredient while Pfizer only uses 30 micrograms. The Moderna booster is a half-dose but it will still be more of a dose than Pfizer.

There is some evidence that Pfizer’s immunity waned more quickly even though it was a higher initial immunity. However, that could be due to confounding variables (Pfizer was released first and so more Pfizer recipients are elderly, whose immune systems are weaker) or due to administration mode (Moderna shots were given 28 days apart while Pfizer shots were given 21 days apart, and the delay may mean better long-term immunity).

Evidently the J&J vaccine tends to stimulate more cellular immunity because part of the vector DNA ends up being transcribed and expressed in addition to the spike protein code. So I am wondering whether it is worthwhile to get the J&J booster on top of my Moderna course. 

[JoeSchmuckatelli]

7 minutes ago, sevenperforce said:

I am wondering whether it is worthwhile to get the J&J booster on top of my Moderna course

Probably. 

 

Sadly that is likely to be both the best scientific and non scientific guess at this point. 

My advice is to read as much as you can, and then make an intuitive judgment - because you are the Guinea Pig for future generations either way 

[tater]

Why would anyone who is not elderly/chronically ill/morbidly obese get a booster?

In my mid-50s, unvaccinated risk is ~0.011% (per Oxford risk calculator given my BMI, etc). Vaccines are only ~50-60% effective vs poor outcomes, so it drops that risk from 11:100k (same as annual auto accident risk) to ~5:100k (about my risk of getting murdered in the US). Anyone younger than me is at less risk (about an order of magnitude for each 20 years age difference).

These vaccines are pretty marginal, certainly worth it for the at risk, but my age bracket (50s) is probably the lower limit where absolute risk reduction is meaningful.

There are at least 2 traditional vaccines in Phase 3 trials right now (inactivated live virus), for something that provides immunity to 20-something epitopes instead of just the 2 in current crop, I might wait for those. Course a majority of people have already had COVID in the US (~56% per CDC, at 4.2X the tested positive count), so they don't need anything, getting was their booster (or live virus vaccination).

 

And I had COVID anyway (as did a whole chain of people I know, all vaccinated, and our chain's patient zero—vaccinated).

[sevenperforce]

55 minutes ago, JoeSchmuckatelli said:

Sadly that is likely to be both the best scientific and non scientific guess at this point. 

My advice is to read as much as you can, and then make an intuitive judgment - because you are the Guinea Pig for future generations either way 

It seems settled that the mRNA vaccines produce a stronger antibody response. It is possible that the viral vector vaccines produce more persistent, broad-spectrum immune system activity at the expense of lower antibody response.

We also have good evidence that if you’ve had a viral vector vaccine, getting a subsequent mRNA booster raises your antibody titers just as high as if you started with mRNA from the beginning.

Arguably, then, if the viral vector vaccine provides enough antibody priming to reap the benefits of the the mRNA booster, the viral vector booster would have enough effect to reactivate the antibody response of the mRNA vaccine, and so getting Moderna+Moderna+J&J might just be the best possible approach.

The Moderna booster is still larger than the Pfizer booster, so I suppose that going Moderna^3 would result in the highest possible antibody count. However, antibody count drops asymptotically so the value of an overwhelming antibody count might be less important.

[sevenperforce]

8 minutes ago, tater said:

In my mid-50s, unvaccinated risk is ~0.011% (per Oxford risk calculator given my BMI, etc). Vaccines are only ~50-60% effective vs poor outcomes, so it drops that risk from 11:100k (same as annual auto accident risk) to ~5:100k (about my risk of getting murdered in the US). Anyone younger than me is at less risk (about an order of magnitude for each 20 years age difference).

Your maths are off.

According to the CDC’s most recently-updated data, the primary mechanism of action for the vaccine is infection prevention. Your antibodies are high enough that you are 85-90% less likely to become infected at all. And that risk reduction is consistent across the range of age and pre-existing conditions. So if you have a million unvaccinated people and a million vaccinated people who all have an otherwise-similar range of ages, lifestyles, heath issues, and exposure risk, any given adverse outcome will be 5.7-9 times more common in the unvaccinated group.

Remember, COVID-19 is much more deadly than polio.

The vaccines are effective at preventing illness because they stimulate antibody production. High antibody counts keep you from becoming infected in the first place, and they reduce the severity and transmissibility of breakthrough infections. If you are in an age group or other risk group that has a weaker immune response, your antibody counts will drop more quickly, and so you need a booster. If it has been more than 8 months since you were vaccinated, your antibody counts have dropped, and so you need a booster.

Not everyone needs a booster. Spacing out shots produces higher immunity response. But keeping antibody counts high across the population is the best way to keep infections, hospitalizations, transmissions, and deaths low. 

22 minutes ago, tater said:

Course a majority of people have already had COVID in the US (~56% per CDC, at 4.2X the tested positive count), so they don't need anything, getting was their booster (or live virus vaccination).

If people were fully-vaccinated and caught COVID anyway then their immune systems aren’t working particularly well and so they absolutely need a booster.

If they got vaccinated after recovering from COVID, then they probably don’t need a booster. 

[JoeSchmuckatelli]

30 minutes ago, sevenperforce said:

people were fully-vaccinated and caught COVID anyway then their immune systems aren’t working particularly well and so they absolutely need a booster.

That's not the correct take-away.  The vaccine isn't 100%.  It does seem to provide some (most) people with the ability to not get sick at all, some people who do get sick have mild symptoms and less fatality, and then there are a very few who (likely because their immune systems are already compromised) have serious cases.

I've two exceptionally healthy friends who were both vaccinated (one Moderna, one Pfeizer) and both got breakthrough Delta variant: neither had to go to the hospital, but for one of my friends it was touch and go whether he should.  (Anecdotal, I know).  The problem is that there are too many variables: such as the blood type thing.  Lots of Type O Pos people had light symptoms, whereas others with differing blood types had harsher runs.  That's only one example  -- but it shows that while effective, the vaccines alone are not the whole story.  We've yet to see any studies (afaik) corelating blood type and break-through cases (likely because breakthrough is statistically rare).  Yet absence of evidence is not evidence of absence.  (My friend who maybe should have gone to the hospital is not O Pos.)

 

Edited October 21, 2021 by JoeSchmuckatelli

[tater]

47 minutes ago, sevenperforce said:

According to the CDC’s most recently-updated data, the primary mechanism of action for the vaccine is infection prevention. Your antibodies are high enough that you are 85-90% less likely to become infected at all. And that risk reduction is consistent across the range of age and pre-existing conditions. So if you have a million unvaccinated people and a million vaccinated people who all have an otherwise-similar range of ages, lifestyles, heath issues, and exposure risk, any given adverse outcome will be 5.7-9 times more common in the unvaccinated group.

This is flat out wrong. VE vs infection has rapidly faded, hence boosters. UK tracks this transparently. 1 dose to 21 days, 2d dose to 14 days, 2d dose >14 days. VE has dropped substantially, and indeed current UK data  (week 41?) shows in all age groups 30+, vaccinated rates (rates, not absolute numbers, as most are vaccinated) of infection are higher in the vaccinated right now.

Literally every human we personally know with C19 right now is fully vaccinated, a few in healthcare setting (doctors) who got it from other doctors—masked in the office (my wife's office mate, for example).

The CDC literally just changed their page a few weeks ago to stop saying vaccines prevented infection, and instead remarks that they prevent poor outcomes.

The Israeli data has VE vs infection dropping to 39% (this work is why they went all-in for boosters, requiring them). The recent Qatar paper drops VE vs infection lower than that.

There was a recent Israeli paper about an outbreak in a healthcare setting, 1 case resulted in a chain that infected 42 others (they have full contact tracing), and I think 38-39 of them (96%) were vaccinated (all but 1 long after their second dose, 1 with just 1 dose). 16 were docs/staff, 2 of the docs/staff were only in contact with 1 wearing a procedure mask, the other in full PPE. Most were mild, but a few people died (all but 1 elderly/sick, one more like my age by also already sick).

EDIT: found paper 38 fully vaccinated, 1 1 dose:

https://www.eurosurveillance.org/content/10.2807/1560-7917.ES.2021.26.39.2100822;jsessionid=Vos62J3vObz45piGf9lAqaRk.i-0b3d9850f4681504f-ecdclive

 

Edited October 21, 2021 by tater

[tater]

PS, of the 8 person chain we know (really 10, since we know the med school attending she got it from at a meeting in Sept she went to, and he got it from his husband (both vaccinated)) everyone had a cold. Some lost taste. Course this is true of everyone we know who got it before vaccines—except of course for the large number that never knew they had it, since the current infection rate in NM is apparently 2/3 of the entire population (IFR 0.356%).

[cubinator]

1 hour ago, tater said:

Why would anyone who is not elderly/chronically ill/morbidly obese get a booster?

Cause I really want Mars to be the thing that kills me. 

[tater]

BTW, with the UK data, while the rates of infection per 100k are higher in the vaccinated pop (almost 2X for the 40-49 year olds, lower for the others), the poor outcomes are markedly lower in all groups. About 1/4 to 1/2 the hospitalizations, and better vs death.

They are certainly protective vs poor outcomes, but they are just not there for protection vs infection, sadly. For most people this is no big deal, as it's just a cold for the large majority of people—maybe a nasty cold, but a cold. For the immunosuppressed, elderly, and chronically ill, even a cold is a bad thing, and for them this is much worse than a cold.

https://www.cdc.gov/pcd/issues/2021/pdf/21_0123.pdf

^^^ useful for risk assessment. 25% of deaths had 11 or more serious chronic health issues (by ICD-10 codes listed). 39% had 6-10 comorbidities. 32% had 2-5, 2.6% had only 1, and just 0.9% were completely healthy.

[Guest The Doodling Astronaut]

In summary (and I hope I don't break a rule saying this): I'm more concerned there isn't enough people getting regular vaccinations vs booster. Getting a booster is debatable, but since I am of the younger generation, I don't think I'll be getting the booster unless it's very recommended.

[tater]

2 minutes ago, cubinator said:

Cause I really want Mars to be the thing that kills me. 

Assuming you are substantially younger than I am, C19 is not a meaningful absolute risk. For people in school (inc college), they are about 10X more likely to die in a car accident each year (that includes walking on sidewalks, ped vs MVAs are subsumed in those stats) than their lifetime chance of getting C19 the first time. And of course, half of us or more have had this (~187M people in the US so far).

This site is pretty cool (Yale/Harvard/Stanford): https://covidestim.org/us

Bayesian "nowcasting" shows actual infections (not tests), Rt, and percent ever infected by county for most all States.

[Nuke]

im of the opinion that the plague ended when i got vaccinated. im not sure if that means i get the booster or not. was at the doctor a few days ago and nobody tried to push a booster on me (these people usually jump on you with a flu shot if given the chance).

i also view masking as being similar to the door close button on an elevator, to give people a false sense of control in lieu of actual control. the efficacy of properly designed and fitted masks in the hands of trained medical professionals was somewhat questionable, they work when coupled with the trained discipline of health care professionals and either one can fail.  in the hands of the general public, i don't think they do a damn thing.

[kerbiloid]

An offtopic question: C19 vs AIDS? Both seem having no effective vaccine. Both caused global panic in their time.

Currently, are they comparable in sense of modern plague?

[JoeSchmuckatelli]

43 minutes ago, kerbiloid said:

An offtopic question: C19 vs AIDS? Both seem having no effective vaccine. Both caused global panic in their time.

Currently, are they comparable in sense of modern plague?

You had to do more than breathe to catch AIDS. 

Thus, not comparable. 

Although both have been a boon for the personal protective gear industries.  That's about it 

[sevenperforce]

10 hours ago, JoeSchmuckatelli said:

10 hours ago, sevenperforce said:

people were fully-vaccinated and caught COVID anyway then their immune systems aren’t working particularly well and so they absolutely need a booster.

That's not the correct take-away.  The vaccine isn't 100%.  It does seem to provide some (most) people with the ability to not get sick at all, some people who do get sick have mild symptoms and less fatality, and then there are a very few who (likely because their immune systems are already compromised) have serious cases.

The problem is that there are too many variables: such as the blood type thing. 

Well, my take-away was certainly not that the vaccine is 100%; it definitely isn't. If people have a breakthrough infection, then it is more likely that they have some latent vulnerability (either due to blood type or due to weak immune response) and so they are more likely to benefit from a booster. That's all I'm saying.

7 hours ago, kerbiloid said:

An offtopic question: C19 vs AIDS? Both seem having no effective vaccine. Both caused global panic in their time.

What do you mean, "no effective vaccine"? All the vaccines authorized for use are extraordinarily effective.

When all this started, we were hoping to get lucky with vaccines that were 40-50% effective at preventing serious illness. Instead we got vaccines that were 85-90% effective at completely preventing infection/transmission and 90-95% effective at preventing serious illness.

They're also not comparable in terms of disease duration and prognosis (AIDS is lifelong and incurable while most COVID-19 cases are asymptomatic and all cases resolve) or prevention (AIDS is 99% preventable by a combination of abstinence, monogamy, and barriers while masking and distancing only lowers COVID-19 transmission risk by 50-70%).

8 hours ago, Nuke said:

im of the opinion that the plague ended when i got vaccinated. im not sure if that means i get the booster or not. was at the doctor a few days ago and nobody tried to push a booster on me (these people usually jump on you with a flu shot if given the chance).

That's probably because full booster authorization only happened yesterday, and even now you're probably not in a booster-eligible group. Doctor's aren't going to push you to take something they're not yet able to give you.

8 hours ago, Nuke said:

i also view masking as being similar to the door close button on an elevator, to give people a false sense of control in lieu of actual control.

Masking as a way of protecting yourself was never believed to be particularly effective. Cheap cloth masks do not offer significant protection to the wearer. Masking is effective, however, for source control: reducing transmission. If I'm in a room with someone who has presymptomatic COVID and I am wearing a mask, my odds are not great; if they're wearing a mask, my odds are much better.

This is one of the first respiratory viruses in human history with a significant presymptomatic contagious period. With most communicable respiratory diseases, you begin to be contagious when your symptoms first emerge, and you remain at the same level of contagiousness until your primary symptoms start to wane. But with COVID-19, you are extraordinarily contagious 2-3 days before you show any symptoms, and by the time you realize you are infected, you are less than half as contagious as when you started. The primary mode of transmission for COVID-19 is superspreader events by presymptomatic carriers who find out later that they are infected (or whose symptoms are mild enough that they never even realize it was more than a head cold).

The goal of masking is not to protect the wearer, but to protect everyone else in case the wearer is presymptomatic and doesn't know it yet.

[sevenperforce]

10 hours ago, The Doodling Astronaut said:

Getting a booster is debatable, but since I am of the younger generation, I don't think I'll be getting the booster unless it's very recommended.

Getting a booster prematurely won't hurt you, but it may reduce the immune response you would receive if you waited and got a booster later. So for many younger people the added protection conferred by a booster is not very significant.

We can think about immunity as two lines of defense. Your antibodies are like riot police; they stop intruders before they even get in. Your T cells and B cells, on the other hand, are like club bouncers; they throw out any intruders who are able to make it past the riot police. The vaccines (particularly the mRNA ones) are effective at preventing infection because they cause your antibody counts to go through the roof. At the same time, the T cell and B cell activation gives you long-lasting protection against serious illness. 

The trouble is that we haven't been tracking everyone's antibody titers. It has been just over 8 months since I was fully vaccinated, but I don't know what my antibody titers were like at that point. If my antibodies have fallen by 50% in the past 8 months, that's fine; I'm not worried. If they've fallen by 95%, on the other hand, I would want to get a booster right away to bring the "riot police" defense back up (even if I know my T cells and B cells are still just as active). The antibodies provide the most protection against transmission, which is my biggest concern (since I'm otherwise fairly healthy).

10 hours ago, tater said:

BTW, with the UK data, while the rates of infection per 100k are higher in the vaccinated pop (almost 2X for the 40-49 year olds, lower for the others), the poor outcomes are markedly lower in all groups. About 1/4 to 1/2 the hospitalizations, and better vs death.

They are certainly protective vs poor outcomes, but they are just not there for protection vs infection, sadly.

Are you sure the age-adjusted rates of infection are higher in the vaccinated population? That's not what I've seen. The numbers of infections are higher in the vaccinated population, yes, but that's because the UK has almost everyone over 18 vaccinated.

The mRNA vaccines are 85-90% protective against infection immediately after vaccination. Protection against infection wanes over time (though it doesn't drop below 55-60%), but protection against serious illness remains high.

[kerbiloid]

27 minutes ago, sevenperforce said:

What do you mean, "no effective vaccine"?

No pox or polio around.

[sevenperforce]

11 hours ago, tater said:

The CDC literally just changed their page a few weeks ago to stop saying vaccines prevented infection, and instead remarks that they prevent poor outcomes.

The CDC never said that vaccines prevent infection and never said that vaccines prevent poor outcomes. The CDC's page says that the vaccines remain effective at reducing the risk of infection and remain highly effective at reducing the risk of poor outcomes.

Excerpts from the current CDC page (last update 9/15/2021):

Early data suggest infections in fully vaccinated persons are more commonly observed with the Delta variant than with other SARS-CoV-2 variants. However, data show fully vaccinated persons are less likely than unvaccinated persons to acquire SARS-CoV-2, and infections with the Delta variant in fully vaccinated persons are associated with less severe clinical outcomes.

In the Moderna trial, among people who had received a first dose, the number of asymptomatic people who tested positive for SARS-CoV-2 at their second-dose appointment was approximately 67% lower among vaccines than among placebo recipients (0.1% [n=15] and 0.3% [n=39], respectively). Efficacy of Janssen COVID-19 vaccine against asymptomatic infection was 74% in a subset of trial participants.

[M]eta-analyses indicate an average effectiveness of full vaccination against SARS-CoV-2 infection of 85%–95% shortly after completion of vaccination.

Studies [of the Delta variant] from the United Kingdom have noted effectiveness of the Pfizer-BioNTech vaccine against confirmed infection (79%) and symptomatic infection (88%), compared with the Alpha variant (92% and 93%, respectively).

Even with waning antibody counts and more contagious variants, the vaccines continue to significantly reduce the risk of primary infection.

5 minutes ago, kerbiloid said:

32 minutes ago, sevenperforce said:

What do you mean, "no effective vaccine"?

No pox or polio around.

It took 184 years for vaccines to fully eradicate smallpox. These vaccines have had about 13 months at most.

[kerbiloid]

18 minutes ago, sevenperforce said:

It took 184 years for vaccines to fully eradicate smallpox

To the date there are effective vaccines against polio and pox.

[Jack White]

47 minutes ago, sevenperforce said:

The CDC never said that vaccines prevent infection and never said that vaccines prevent poor outcomes. The CDC's page says that the vaccines remain effective at reducing the risk of infection and remain highly effective at reducing the risk of poor outcomes.

Excerpts from the current CDC page (last update 9/15/2021):

Early data suggest infections in fully vaccinated persons are more commonly observed with the Delta variant than with other SARS-CoV-2 variants. However, data show fully vaccinated persons are less likely than unvaccinated persons to acquire SARS-CoV-2, and infections with the Delta variant in fully vaccinated persons are associated with less severe clinical outcomes.

In the Moderna trial, among people who had received a first dose, the number of asymptomatic people who tested positive for SARS-CoV-2 at their second-dose appointment was approximately 67% lower among vaccines than among placebo recipients (0.1% [n=15] and 0.3% [n=39], respectively). Efficacy of Janssen COVID-19 vaccine against asymptomatic infection was 74% in a subset of trial participants.

[M]eta-analyses indicate an average effectiveness of full vaccination against SARS-CoV-2 infection of 85%–95% shortly after completion of vaccination.

Studies [of the Delta variant] from the United Kingdom have noted effectiveness of the Pfizer-BioNTech vaccine against confirmed infection (79%) and symptomatic infection (88%), compared with the Alpha variant (92% and 93%, respectively).

Even with waning antibody counts and more contagious variants, the vaccines continue to significantly reduce the risk of primary infection.

It took 184 years for vaccines to fully eradicate smallpox. These vaccines have had about 13 months at most.

It's better to have one than just do not have it. You have more chances to live if you do one, that's just a real statisics. But, well, even if you do not believe and do not want to do it it's your choice and you are free to do so. 

[AtomicTech]