There’s too many men, too many people
Making too many problems
And there’s not much love to go around
Can’t you see this is the land of confusion

From “Land of Confusion”, Genesis 1986

If you are not confused by the recent machinations of the FDA and CDC regarding recommendations for getting a Covid-19 Booster shot, then you either have the gift of superhuman intelligence, or have not been paying attention. I was delaying this “update” until official recommendations were made by the two agencies for who should get boosters and when. Disagreements between the CDC, FDA, and Biden administration have led to a messaging quagmire, with the public unsure how to proceed. This morning, in a stunning departure from bureaucratic etiquette, Dr. Rochelle Walensky, head of the CDC, overruled her own advisers and expanded the recommendations for vaccines for health care workers, teachers, and other members of the public at higher risk. 

The dog and pony show that is the FDA/CDC is not inspiring confidence from the public, and risks further alienating an already angry, frustrated, and fed-up population.   

Vaccines are in abundant supply, and many pharmacies are giving booster shots to just about anyone who wants one. Given this reality, I will share my own vaccine recommendations with the intent of trying to achieve the best health care outcomes for my patients. The rationale for each of these recommendations is included at no extra cost.

1)       If you got the Johnson and Johnson vaccine, your booster should be an mRNA vaccine, preferably Moderna. A second shot with J&J does produce a hefty antibody response, but the mRNA vaccines perform better in multiple categories including less side effects, better activity against the Delta variant, and longer duration of action. A small number of women under age 50 developed serious blood clots in large veins in the brain from the J&J vaccine. There is no reason to get it when other vaccines are readily available. 

2)      Everyone over 60, who is at least 6 months out from their last dose of vaccine, should get vaccinated with the same vaccine they got originally. (If you got J &J, get Moderna). This is based on Israeli data, showing that vaccine efficacy of the mRNA vaccines begins to fall off after 120 days. At 180 days a significant number of breakthrough infections have occurred – almost all the breakthroughs occurred when the Delta variant became more prominent. Infections were more severe in the population over 60, though there were very few hospitalizations and even fewer deaths.

3)      Anyone with chronic health problems, age 18 or over, such as diabetes, current treatment for cancer, or rheumatologic illness requiring immune suppressant treatment, who received their last shot more than 4 months ago, should get a booster now, with the same shot they got previously  (Not J&J). There is more virus around right now than there will be in one month or two months, so getting a booster when you have the highest risk of getting infected makes sense. 

4)      Healthcare workers and first responders should all get a booster, now. Why risk transmitting disease to patients when antibody levels fall? Why risk getting Covid 19 yourself?

5)      Teachers, and others who interact with a potentially unvaccinated population should get a booster now. 

6)      Those 59 and under who are healthy and have been vaccinated, do not need to rush to get a booster. But if you travel frequently, are caring for elderly parents, have young unvaccinated children at home, go ahead and get one, it won’t hurt you and may protect someone else. 

Viral prevalence is declining in many parts of the country, after another huge wave of infection over the last two months. Hospitalizations and deaths have not yet reached their peak, as they lag behind case numbers by several weeks. If the virus were to surge again, it would likely have to be with a novel strain, which evades existing immunity in the population that may be as high as 80-90% in vaccinated locales. States with low vaccination rates such as Idaho, Alaska, and Wyoming, are suffering, with few available hospital beds. If you are having a heart attack in Idaho, you may as well stay home, chew some aspirin, and drink some red wine, because you are not likely to find a hospital that has room for you.

In Maryland cases are up a bit with the opening of schools, but the numbers have remained manageable.  Some hospitals are cutting back on elective surgeries temporarily, to keep enough beds open to manage Covid cases. Vaccines for younger children (Pfizer first) are likely to be approved over the next 4-6 weeks and this will further the quest to end this pandemic.  

It is pretty clear to me that the public is done with this pandemic. Football stadiums are full, Broadway is reopening, traffic is horrendous, and it is difficult to get a table in any half decent restaurant. It seems people have decided that there are worse things than dying and one of them is living in isolation, indefinitely. We are all ready to take our chances. But take your chances with the vaccine on board, three doses, if that applies to you.