Flu season is coming soon, and with everything being open, we are probably going to have many more cases of the flu this season compared to the last two. We feel the optimal time to get vaccinated in San Diego is late October or November because flu season here peaks around January or February, and by vaccinating around November, you will have the most antibodies to protect you around the peak of flu season. However, if you are traveling out of town before November, you can certainly get your vaccine sooner. The CDC usually recommends getting the flu vaccine right now, as soon as it's available, but that's because they are more concerned about developing "herd immunity" in a community -- if more people are vaccinated early on, there is less chance that influenza hits that community hard later on.
Once again, we will be carrying TWO different flu vaccines. We have the usual 4-strain (quadrivalent) flu vaccine that everyone is eligible to receive, called Flucelvax. We also have a HIGH DOSE 4-strain vaccine called Flublok. This vaccine has three times the amount of antigen for 4 different strains, and studies show that it gives 30% better protection than the usual 4-strain flu vaccine when tested in patients ages 50 and above. There is also a "senior” flu shot called Fluzone High-Dose which also protects against 4 strains of influenza, and it is usually the one that most pharmacies will try to administer to seniors. Given a choice between the two of them though, I would choose Flublok because this vaccine is not grown in eggs (unlike the Fluzone), which prevents the possible mutations that can occur in egg-grown vaccines that can alter the final product. However, the difference is not huge, so if you can’t get Flublok, the Fluzone High-Dose is certainly a good substitute. Therefore, we are recommending the Flublok vaccine in all patients ages 50 and above, although you certainly can get if you are under 50 and you choose to. If you get your flu shot elsewhere, please let us know so we can document it in our records.
Most insurances, including Medicare, do cover all flu shots, but if it is not covered, Flublok costs around $80. If you happen to be in the Ximed building on a Tuesday, Wednesday or Friday starting in October, you can just stop by the office to see if you can get the vaccine. If you want to come in on a Mondays or Thursday, please call us first. If you have questions, please contact our office by phone at 858-452-7040 or through your web portal (accessed through www.sun-md.com).
Update on the ALL-NEW Bivalent COVID-19 Boosters
New COVID-19 booster vaccines are now available and everyone should read the information below:
When should I get this new booster?
The CDC recommends that you get your bivalent booster at least two months after your last COVID vaccine, whether it was the primary series or a booster shot. Even people who have received four shots already should still get this one because it gives more protection against Omicron. People who received one shot of the Johnson and Johnson vaccine should also get this new booster. Having said that, there are many experts that feel that getting another booster shot so soon after getting the previous one may not elicit a significant antibody response. Indeed, studies show that you build more antibodies if it has been at least 4-6 months since your previous vaccine. Therefore, I feel that the optimal time to receive this new bivalent booster is at least 4-6 months after your last COVID-19 shot.
What if I recently had COVID?
If you have had COVID in the last few months, it is a good chance that you were infected with Omicron, so this booster may not be as important to get right away. The CDC states that as soon as you have recovered from a COVID infection, you can receive a booster shot, but they do acknowledge that waiting about three months after an infection may be a better option because the infection will likely give you some protection already, and the additional time will allow the booster to give you a better antibody response down the road. Therefore, I also recommend waiting at least 4-6 months after recovering from COVID to get this new booster.
I heard that this booster has not been tested in humans. Is it safe?
Both the Pfizer and Moderna bivalent boosters are pretty much the same as the original vaccine. There were some human studies that incorporated the original strain plus the Omicron BA.1 strain earlier this year, and these initial studies showed a significant elevation in the neutralizing antibodies against Omicron compared to the original vaccine. However, BA.1 quickly became overtaken by Omicron BA.4 and BA.5 strains, so the manufacturers change their “formulas” to develop the current bivalent vaccines. While we don’t have hard numbers from human trials showing how much better these boosters are against protecting against Omicron, the studies are currently ongoing. This is a very similar situation to the annual flu vaccines we give. We try to predict which strains of influenza are going to be most dominant each winter and tailor the influenza vaccine to those strains. We don’t wait and test them each year, because the flu season would be over by the time we got the results back. Similarly for this new bivalent vaccine, we don’t want to wait to test it because we may have a different strain in six months. In summary, this vaccine is still very safe.
I’m in! Now how do I get this booster?
We did receive our first delivery of the Moderna bivalent booster and are administering it in anyone ages 50 and above or anyone who has a significant underlying condition that puts them at risk for complications. If you are in this category and happen to have an appointment in the office in the next few weeks, you may be able to receive the vaccine at your appointment, so let us know, preferably by sending a message through the patient portal. If you are in this category and would like to make an appointment for the vaccine, please send us a message through the portal specifying the days and times that you would be able to come in. Most likely, we will be administering these shots on Tuesdays, Wednesdays, and Fridays. And finally, if you are healthy and below 50 and would like to receive this vaccine as soon as possible, you can put your information in this survey and we will call you if we have extra shots that need to be used up before the end of the day, or after we open up the vaccine appointments to everyone.
Other than at our office, you can also get an appointment at a local pharmacy to receive this booster, or book an appointment through myturn.ca.gov when the site opens up.
Should I get my flu shot early so I can get it with my bivalent booster now, or should I wait until November to get them both?
There is no one right answer to this. If you are over 65, received your last booster six months ago, have not had COVID yet, and plan on taking a trip or attending a large indoor gathering in the near future, you can certainly get them both now. Without having such an exposure coming up, you can get your COVID booster now and wait until November to get your flu shot. If you just had COVID-19 three months ago, I would wait until November until getting both the flu and COVID booster. Remember, it is not a problem to get the COVID booster with any other vaccine.
Hopefully that answers your questions. Fingers crossed that this winter will be much better than the last two!
As everyone knows, we are having a large increase in the number of COVID cases in San Diego due to the BA.5 strain of Omicron, so if you have any symptoms at all, even if you think it’s just allergies, please test for COVID and let us know if you are positive. And remember, masks are STILL REQUIRED in our offices. We’ve had several people that have been here for their appointments, only to start feeling sick and testing positive for COVID the following day. Masks are still important in preventing us all from getting infected.
COVID-19 booster update
If you have not had your COVID-19 Booster, please read this!
As I discussed last month, I do think it is important for everyone to get a booster shot for COVID-19, even if you are young and have no medical conditions. I discussed the data on the last blog entry, but some people still feel that they don’t need a third shot. Please remember that there are several vaccines that we give that do come in a series of three. HPV vaccines (to prevent cervical cancer) and hepatitis B vaccines are both given as a series of three shots in six months. When they were first released, they were designated as a 3-shot series because the vaccine companies had many years to test and trial various dosing regimens to discover the optimal dosing regimen. When they realized that 3 shots were best, they released them as 3-shot series. Because the COVID-19 vaccines were developed and released without the benefit of years of testing, they were initially thought to be a 2-shot regimen, but after many months of study (and in the face of mutated variant strains of COVID-19), the vaccine really should be thought of as a 3-shot regimen. Therefore, if you only had two shots, don’t look at the third shot as a “booster.” Having had two shots, you should consider yourself as not having the full series for the vaccine, and you should come in to get that last shot to complete the full series.
What about a fourth shot?
Many people are still asking about a fourth shot, especially if they received their third approximately six months ago. At this point, there are some people that should definitely receive a fourth shot, so if you are one of these people and have not received a fourth shot, please contact the office:
For everyone else, you really don’t need a fourth shot. Studies in healthcare workers in Israel show that a fourth shot do increase COVID antibodies, but they don’t really prevent infection with Omicron. And unfortunately, the Omicron-specific boosters currently being developed by Pfizer at this point don’t appear to work any better than the original booster shot. There is some discussion that a fourth shot may be recommended in the fall since respiratory viruses increase in the fall and winter, just like cold and flu viruses, and we may see a resurgence of COVID-19 then. And of course, if another variant starts to emerge, all of these plans may change as well.
What if you still want a fourth shot?
Since both Pfizer and Moderna have received full FDA approval, it is possible to receive a fourth shot as an “off label” use. Some people may want to get a fourth shot before they travel, especially if someone at home has a compromised immune system. You should understand that the third shot alone gives you excellent protection against severe illness or hospitalization, and a fourth shot really doesn’t do much to lower that chance any further. It is also important to know that although everyone in our own office received our third shots as soon as they were authorized, no one in our office is currently planning on getting a fourth shot at this time. Despite all of this information, if you still would like to receive a fourth shot, contact our office, and we can put you on a list to call. We still have vaccines that may expire before being given, so if a vial is open and will otherwise go to waste, we can call you to receive the vaccine.
At home COVID-19 test kits
The two at-home rapid antigen tests that I discussed last time are now available for purchase. Both of these tests seem to be better at detecting Omicron compared to some of the other available tests. Clinitest by Siemens is available at Amazon through this link. In addition, the Roche COVID-19 At Home Test is available through the Optum Store. If you need to buy more at home tests, these are the ones I would recommend.
I hope this downward trend in COVID-19 infections continues, and that the worst is really behind us. I will keep you all up to date if anything new develops.
COVID-19 boosters, tests and masks
As you are all aware, COVID-19 infections are running rampant throughout our community. Unfortunately, our office staff is not excluded from this. As careful as we have been, we have had staff test positive over the last few weeks. If any of our patients are potentially exposed, we will notify you to let you know what you should do. But because of this, just like many of the hospitals and medical facilities around the nation, we have been and currently are short-staffed. In addition, we are also fielding an exorbitant number of phone calls related to COVID symptoms, testing, infections, and other related questions. Please be patient with the staff over the next few weeks while we do our best to manage this surge in cases, and if we do not get back with you as soon as we usually do, know that we are working as quickly as we can. We are trying to address patient issues first, and we will try to get to the administrative issues as soon as we can.
If you have not had your COVID-19 Booster, please read this!
Last month, I encouraged all patients to get a COVID-19 booster vaccine, even if you are young and healthy. Currently in San Diego, only about 30% of eligible patients have been boosted. We now have data to show just how important a booster is, and it also sheds light on why there have been so many breakthrough infections. A large study done in the UK in December evaluated almost 400,000 adults with symptomatic COVID-19 infections, and they determined whether patients were infected with Delta or Omicron strains. Individuals who received two doses of Pfizer still had a 60% protection against Delta six months after their second shot, and individuals who received two doses of Moderna still had >70% protection against Delta at six months. Getting a booster increased protection against Delta to about 90% up to about 2½ months after the booster dose (which was as long as the study was for). The problem was with the Omicron variant – in patients who did not get a booster, protection against Omicron dropped to about 10% at six months after the second vaccine shot! This shows that over time, the vaccines were not very effective against this new highly-mutated strain. Getting a Pfizer booster after initially getting Pfizer bumped up protection against Omicron to greater than 60% again, and by 2½ months after the booster, protection dropped down to about 50%. People who got the Moderna booster after getting Pfizer got perhaps a little higher level of protection. They did not have enough data for boosters in patients who initially received the Moderna vaccines. All of this goes to show that the booster shots are necessary in everyone to help prevent the transmission of the virus, so please get your booster shot.
What about a 4th shot?
At this point, most people do not need a fourth shot of the vaccine. The preliminary studies in Israel show that although antibody levels increase after the fourth shot, it does not appear to be enough to prevent Omicron infections. Pfizer is working on an Omicron specific booster which may be ready around March 2022. However, hopefully by that time, Omicron will be in retreat.
What if you test positive for COVID-19?
Last month, I recommended that patients 65 years and over, or those with medical conditions that put them at high risk for complications, should get monoclonal antibody treatment if they test positive for COVID-19. Unfortunately, what we have since discovered is that of all the different monoclonal antibody treatments available, only one is effective against Omicron, and the supplies of that one are very low. Therefore, the Monoclonal Antibody Regional Centers are often not able to accommodate everyone for treatment. There are also very limited supplies of oral medicines Paxlovid and Molnupiravir at a very small number of pharmacies around San Diego, so if you test positive and feel that you are at high risk for complications, please contact our office to discuss. What you should remember though, is that if you have been fully vaccinated, your individual risk of dying from COVID is very small, so even if you don’t end up getting treatment, you will most likely do fine. According to a validated risk calculator (www.qcovid.org), a vaccinated 75-year-old woman with active lung cancer has LESS THAN 1% CHANCE of dying. Of course, if millions of people get COVID, there will be many people that die, but your individual risk of dying if you’ve been vaccinated is still very low.
At home COVID-19 test kits
As many of you know, the government is now providing 4 free at-home test kits for each household. You can register at www.covidtests.gov to get your kits mailed to you in 1-2 weeks. The government has also required that all insurance companies reimburse you for up to 8 at-home tests per month. Many insurance companies probably do not yet have the mechanisms set up to reimburse you for these tests, but make sure you save your receipts so you can request reimbursement in the future. Remember, the at-home tests only detect the viral antigen if enough antigen is present, so if you test too early after exposure, there may not be enough virus to turn the test positive, and you may want to retest after a few days. There has been some discussion that Omicron replicates more in the throat so that a throat swab may be more accurate than a nasal swab. Although this might be true, all of the at-home test kits were developed to be used with a nasal swab, so the FDA does not recommend using them for throat swabs. Finally, the studies show that the current home tests may not be as good at detecting Omicron compared to the previous strains. However, two new tests have received Emergency Use Authorization and seem to be better at detecting Omicron, and hopefully they will become available in the next few weeks. These tests are manufactured by Siemens (called Clinitest) and Roche (currently called SARS-CoV-2 Rapid Antigen Test).
With regards to masks, we have known that N95s are the most protective, followed by KN95, then surgical masks, and finally cloth masks. There are 2 important things to know about how well a mask works: how well does it filter and how well does it fit? The reason N95, KN95 and surgical masks work better is because they FILTER particles, including viral particles, when air moves through the material. The tangled fibers in the material of a N95 mask can trap particles and keep them from passing through the mask. Simple cloth masks simply do not filter particles as well. However, the FIT of a mask is just as important. N95 masks almost always have 2 rubber bands that go behind your head so that the mask is plastered against your face, and no air can leak out around the mask. If your N95 is too big or you’re not using both bands, air can leak from the sides, and the mask is no longer as effective. If you wear a KN95 mask, make sure you bend the nose piece to the bridge of your nose so that air doesn’t go in and out of that gap. And although surgical masks are made of material that can effectively trap particles, they don’t fit as well against your face so that air (and particles) can bypass the mask by escaping around the edges. These masks ARE effective, but just not as effective as N95 masks. So if you’re going to “double mask,” it does not make sense to put 2 surgical masks on top of each other, because air will continue to leak out around the sides. If you are going to double mask, use a surgical mask underneath, covered by a cloth mask that is tight enough that it helps plaster the edges of the surgical mask against your face so there is less chance of air leaking around. And of course, this explains why just wearing a face shield without a mask makes no sense in protecting you from COVID-19.
The government is distributing 3 free N95 masks to each individual in the US in the next week or so, although the details about how to get these are still not known. N95 masks may be the most protective, but as anyone who has worn one can tell you, they are not comfortable because they are plastered tightly against your face. I would recommend wearing one whenever you are in an indoor situation where there is a higher likelihood of encountering people with COVID-19, but I do believe in the statement that the best mask is the one you’re willing to wear. If you use a N95 but keep taking it off because it’s uncomfortable, it is not as effective as a surgical mask you are willing to keep on. You can re-use the masks, and when you need to buy more, here is an excellent article from the New York Times that discusses the different types of masks. Because there are also a lot of fake masks on the market, the CDC has published a guide for identifying fake N95 masks.
Once again, this is a lot of information to digest. Stay safe, and we will keep our fingers crossed that in one or two months, things will be looking much better!
As many of you know, the omicron variant of the COVID-19 virus is quickly beginning to spread throughout the US. While it does not appear to be more deadly than the Delta variant, it is much more contagious, and even people who have been fully vaccinated and boosted have been getting breakthrough infections. Fortunately the breakthrough infections are generally mild, and individuals recover well, but it is certainly possible if you have coexisting medical conditions that the infection may be more serious. Contrary to my recommendations from last month, with this new data about Omicron, I am recommending that ALL PATIENTS now get a COVID-19 booster vaccine. We carry both Pfizer and Moderna vaccines at the office but are giving them only certain days of the week, so if you want to receive a booster, give us a call.
What if you test positive for COVID-19?
Neither previous infections nor the COVID-19 vaccines provide you with 100% protection against getting COVID-19. Therefore, even if you’re vaccinated, if you have any symptoms (fever, cold symptoms, unexplained muscle pain, etc.) that could be due to COVID, I encourage you to get tested as soon as possible. You can do an at-home test or call the Scripps COVID nurse hotline at 858-261-8431 to schedule a drive-through test. Important things to remember if you do test positive:
Medicare genetic testing fraud alert
Recently, we’ve had several patients contact us about genetic testing. Apparently, there has been a known issue where patients are being targeted through telemarketing calls, booths at public events, health fairs, or door-to-door visits. The Office of the Inspector General had issued a report a couple of years ago, but it is only come to our attention recently. Essentially, fraudsters are telling individuals that these tests were ordered by us, or that they are completely covered by Medicare. Sometimes they have some of your medical information and make it appear that we were the ones that wanted you to have the test. If you receive this information, please do not agree to be tested. If you have questions about genetic testing, please contact our office for an appointment to discuss.
Lipid panel delays
Apparently, there is a shortage of reagents used to run lipid panels, so many of the tests are having to be sent out. Be aware that you may not receive the results of your lipid panel in the usual time frame, and that the results may look different than before because they may be run by a different lab.