Infectious disease experts Cindy Noyes, MD, and Tim Lahey, MD, MMSc, join pulmonologist and critical care medicine physician Gil Allen, MD, to weigh in about boosters, mandates and more.

1. Why are some vaccines, like polio, one and done while others need annual boosters?

Most vaccines – against hepatitis B and measles and beyond – involve getting multiple shots. Getting more than one dose of a vaccine generates larger immune responses which can be important to getting full protection. Influenza vaccines require annual vaccination because the influenza virus changes enough from year to year; previous shots don’t offer enough protection against new viruses. 

We now know that getting multiple COVID-19 vaccine doses can enhance immune responses and in some people provide longer protection from serious illness. We don’t know yet if COVID-19 will change often enough to require vaccinations every year or some other frequency. – Tim Lahey, MD, MMSc.

2. Vaccine mandates have a long history before COVID-19, yet generated some controversy this year when applied to COVID-19 vaccines. What justifies vaccine mandates? 

Vaccines protect the most vulnerable members of society if enough people get vaccinated. When too few people are vaccinated, outbreaks happen that can be especially dangerous for people who are medically vulnerable. That leads to a challenge: one individual’s decision not to get vaccinated can endanger their neighbors. That means that free will has limits: Just like rules against driving recklessly or smoking in restaurants help protect our neighbors, vaccine mandates do the same thing. 

Vaccine mandates are common and certainly not new. One example we’re all familiar with are vaccine mandates in schools. School-age children attending public schools are required to get their childhood vaccinations (like measles, mumps and rubella) to keep all of the children and staff safe. 

Importantly, these vaccine mandates are put in place only after we see if voluntary immunization is enough, and only in response to a serious threat to wellbeing such as COVID-19. – Tim Lahey, MD, MMSc.

3. Do I have immunity if I already had COVID-19?

COVID-19 vaccination and COVID-19 infection can confer some degree of immunity against future infection. There is also a CDC study from Kentucky suggesting that people who have been infected and vaccinated showed more protection from future infection compared to people who were only infected. 

What we can tell you about immunity after infection is that it’s unpredictable. For instance, we expect immunity after infection after chicken pox and measles and all sorts of other infections, but the type and duration of that protection is unpredictable. And there clearly have been reinfections documented in folks who have had infection and then get exposed again. Vaccines allow for effective and durable protection. 

We don’t want to risk infection if we have the means to protect ourselves and others. Even a young, healthy person can develop severe symptoms of COVID-19 and ‘long COVID.’ Any time we can protect ourselves through vaccination, we should. – Cindy Noyes, MD.

4. When will the pandemic be over? Will COVID-19 ever be eliminated? 

This is a tough one. I think the best we can hope to ever achieve at this point is for the global surge of COVID-19 to ultimately slow down to a place where we see small, random outbreaks regionally, but I am not an infectious diseases epidemiologist. I suspect COVID-19 is here to stay and that it is only a matter of time before we encounter the next, potentially more elusive or virulent variant.  – Gil Allen, MD.

I suspect we will learn to live with COVID-19. As more and more people become vaccinated, the risk of exposure and certainly the risk of severe disease will decrease, but I anticipate we will continue to see people develop infections. What we don’t know is whether this will become a seasonal occurrence (like other coronaviruses, RSV and influenza) or be sporadic. For now, things like masking, physical distancing, in addition to vaccination will continue to be important to reduce the number of infections, especially in immune-compromised hosts. As the infection rates decline and our population becomes more protected, we will be able to decrease these prevention strategies, gradually. – Cindy Noyes, MD.

One of the most important learnings from the pandemic is that nobody can predict the future with any accuracy. That remains true. While United States cases, hospitalizations and death are falling as of this writing in October 2021, and we are all hoping that means we are moving back toward a more normal winter, we really cannot know for sure what will happen in the coming months or years. What we do know is that high levels of population vaccination and wearing masks when case counts are high will get us back to normal life sooner. – Tim Lahey, MD, MMSc.

5. Do breakthrough infections mean the vaccine isn’t working?

It’s important to differentiate between breakthrough “infections” and breakthrough “severe disease.” Breakthrough “infections” have been seen in higher numbers with the delta variant, but the incidence of breakthrough “severe disease” — either requiring hospitalization and supplemental oxygenation or ICU admission — has remained very low, and that is reassuring. Vaccinated patients with breakthrough disease also appear to be recovering much more quickly. – Gil Allen, MD.

6. Is COVID at-home testing reliable or accurate?  

The reality is that COVID-19 at-home testing is less sensitive than PCR testing. The at-home tests may produce more false negatives and false positives, therefore they should NEVER be used for testing symptomatic individuals because a negative test does not provide sufficient reassurance that a patient is COVID negative. These test are best used for regular, episodic screening in asymptomatic people, to alert individuals (by a new positive test) when they might require a follow-up confirmatory PCR test. – Gil Allen, MD.

7. Is the Merck antiviral drug promising?

On October 1, Merck put out a press release saying that their oral antiviral drug molnupiravir reduces hospitalizations and death by about 50 percent in people with mild to moderate COVID-19. Merck also claims that the drug is quite safe. This news could be exciting but should be received with healthy skepticism as well. Scientists and clinicians need a chance to review the data carefully and in an unbiased fashion. Sometimes industry announcements like this are reason for celebration, but other times that closer review uncovers reasons to temper that enthusiasm. – Tim Lahey, MD, MMSc.

8. Do you think we’re headed for a “twindemic” as flu season overlaps with COVID-19?

Our hope is that through wide adherence to flu vaccination and masking, we can potentially reduce the size of our seasonal influenza burden. We saw a rise in RSV, a respiratory virus, among children this past summer as masking mandates relaxed in daycare and summer camp settings. Our hope is that a more stringent adherence to masking in schools will also help mitigate the spread of flu and RSV in children, as observed last year, but our schools are more densely populated now compared to last year, so this remains uncertain. – Gil Allen, MD.

9. With regards to COVID, what are you feeling optimistic about? Are there any good trends, data coming to light? What feels like progress?

We have learned a lot through our efforts with COVID-19. We’ve learned the value of masking and physical distancing and how that protects us from transmission and infection from respiratory viruses; we’ve seen herculean efforts to produce incredibly effective vaccines in a short period of time—not because the process was hastened but because of the massive amount of work done by numerous groups to produce and vigorously evaluate the vaccines. We’ve all become experts in appropriate use of PPE. Although we are all ready for a break, we’ve been able to work together to keep each other safe. We’ve moved mountains with providing telehealth when in the past we didn’t think it was feasible.  Although we have ongoing work to finish, I think we’ve come a long way in a short period of time. – Cindy Noyes, MD.

Although vaccination rates still remain lowest in the Southeastern U.S. and mid-northern mountain states, vaccination rates continue to gradually rise everywhere, including in so-called “late adopter” states. Even among the states where vaccination rates are lowest overall, such as Alabama (43.4%) and Idaho (42.%), the vaccination rate for their most vulnerable demographic (age 65+) is now nearly 80% in Alabama and 89.1% in Idaho.  Furthermore, the overall rate in the U.S. for having received at least one dose of the vaccine has continued to steadily rise between Aug 15, 2021, and Oct 10, 2021, from 59.6% to 65.5% (including children under the age of 12). Currently 84% of those over age 65 are fully vaccinated while two-thirds of those over the age of 12 are fully vaccinated. Total number of cases and deaths have been steadily declining since the beginning of September. – Gil Allen, MD.

Drs. Noyes, Lahey and Allen all practice at UVM Medical Center. 

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