COVID-19 Boosters
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:

• Try to contact trace anyone you have been in close contact (6 feet for a total of 15 minutes or more in a 24-hour period) starting from two days before you first started having symptoms. Those individuals should get tested right away if they have any symptoms, or 5-7 days from their last contact with you if they have no symptoms. At this time, if they are fully vaccinated, they do not need to quarantine, but if they are not fully vaccinated, they should quarantine for 14 days, even if they test negative in the interim.
• If you are 65 years or over, or if you have medical conditions that put you at high risk for complications, you should get monoclonal antibody treatment even if you have been fully vaccinated and boosted. At this time, this is still the best treatment for preventing hospitalization and death from COVID-19, although they need to be given early. This is important even if you feel that your symptoms are mild. If you are unsure if you qualify, you can call to see if you qualify for the treatment at 619-685-2500. MONOCLONAL ANTIBODY TREATMENT IS FREE.
• If you do not qualify for the monoclonal antibody treatment, there are other medications that may be helpful at preventing progression of the infection. National studies are currently investigating whether certain treatments (fluvoxamine, inhaled fluticasone, metformin, ivermectin) may prevent worsening of symptoms or hospitalization. If you are interested in participating in any of these studies (and I do encourage you to), please contact them at one of their websites: www.Activ6study.org and www.covidout.com.

 
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.

There is a lot of discussion now about whether all adults should get a booster for COVID, even if they are at a low risk for complications. If you have risk factors such as increased age or certain medical conditions that put you at a higher risk for complications from COVID-19, or you are in a job that puts you at higher risk of contacting people with COVID-19, you should definitely get the booster. However, there are many young and healthy people who are wondering if they should get the booster shot. While I can’t answer that question for everyone individually, here are some my thoughts about this:

• Many health experts are recommending that all adults ages 18 and over get a booster shot for COVID-19. From a public health standpoint, this makes sense. The booster shots have very few side effects and can provide additional protection against becoming infected. We do know that the immunity that you get from the regular series of the vaccine does begin to fade after a few months, and that getting a booster shot decreases your chance of getting infected with coronavirus, as well as making it less likely to transmit it to someone else. From a strictly public health standpoint, the more people that get a booster shot, the less likely they are able to transmit the virus to other people in the community who have not been vaccinated, can’t get vaccinated, or are at high risk for complications if they happen to get a breakthrough infection. Therefore, if you want to “do the right thing” and protect other people in the community, go ahead and get a booster shot even if you are at low risk.
• Some people understand that the risks of side effects from vaccines are very low, and they would like to be as protected as possible against all kinds of infections. Even if you are healthy and are at low risk for major complications from COVID-19, a small percentage of people who get the infection then develop long-term symptoms even after they recover, and the best way to prevent that is to avoid getting infected in the first place. If you are afraid of getting “long-haul” COVID-19 symptoms, you should go ahead and get a booster shot.
• Some people are not afraid of getting COVID-19, but they are around kids who are too young to get vaccinated, or are around people who are older or have significant medical conditions that puts them at risk for complications from the virus. You may be at risk for unknowingly transmitting the virus to these individuals, who can then develop a serious case of COVID-19. If you are in this situation, you should go ahead and get a booster shot.
• Some people may have had the full series of COVID-19 vaccine but then several months later, end up with a mild breakthrough case and are now totally recovered from it. These people can be considered as if they already had a “booster” by actually getting infected with the virus itself. Although the experts still say you should get a booster shot, I feel that it may not truly be necessary right away. It is unclear at this point whether getting infected with the Delta variant after receiving a full series gives you as much protection as a booster shot, but from a scientific standpoint, it is likely to give you pretty good protection. I would probably wait about 4-6 months after recovering from a breakthrough infection and then actually getting a booster shot at that point, although it would not hurt you if you get it earlier.
• Some people have been fully vaccinated but had significant side effects from the vaccines and are therefore hesitant to receive a booster shot. If your side effects were over within a few days and you have no residual from it, I would still say it is best to get the booster. If you feel like your symptoms were much more severe, you can certainly make an appointment and we can discuss your individual situation.
• If you are someone who is at low risk for complications, are not around anyone at risk for complications from COVID-19, and you plan on staying at home with very little interaction with other people for the next several months, that I feel that it is reasonable to hold off on a booster shot for now.

The bottom line is that if you are 18 years or older and want to get a booster, you should be able to get one. We will have both Pfizer and Moderna vaccines in the office, so call for an appointment.
 
The Omicron variant
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Just a quick word about the recent news this weekend regarding the discovery of the Omicron variant, initially seen in South Africa but now being found in many other countries around the world. Although many people are worried about this variant because it has so many mutations on the spike protein, we don’t know yet at this point if it is much more transmissible or possibly more deadly than the current Delta variant. More information will continue to be coming out within the next week or two. Remember that even if we do see more people that are hospitalized with a new variant, it does not mean that it is more deadly – it could just be more transmissible. If the old virus causes 10% of people to be hospitalized and it infects 1000 people, we will see 100 people in the hospital. However, if the new variant also causes 10% of people to be hospitalized but it is much more transmissible, it could infect 10,000 people, and we would therefore see 1000 people in the hospital. People should not panic at this point, but I would continue to wear masks indoors if you are going to be in close proximity with many other people. While that is true that the face masks we wear do not provide 100% protection against transmitting or becoming infected with coronavirus, it is certainly better than not wearing a mask. Furthermore, wearing a mask is respectful to the people around you, as they may be at higher risk for complications from the infection, and wearing a mask decreases the risk of you transmitting anything to them. Stay tuned, as more information about the Omnicron variant should be discovered in the next few weeks.

Right now we do NOT have any COVID-19 vaccines in the office. Vaccine storage requirements recently changed, and we are in the process of getting re-certified. The earliest we will get any is November 1, but it is not guaranteed. Please do not call the office to schedule any boosters until after that date. If you get the booster at a local pharmacy, please let us know so we can document it. With the CDC coming out with their guidelines last week, here is what I am recommending regarding COVID-19 vaccine boosters:

• Pfizer: Boosters have already been authorized and are recommended at least six months after your second dose of Pfizer if you fall into the following categories:
  • You SHOULD get a booster if you are 65 years or older; or you live in a long-term care setting; or you are age 50-64 and have underlying medical conditions ; or you age 50-64 and are at increased risk of social inequity 
  • You MAY get a booster if you are age 18-49 and have underlying medical conditions or are at increased risk of social inequity; or you are age 18-64 with no underlying medical conditions but are in an occupation which puts you at a higher risk of exposure to COVID.
• Moderna: Boosters are now authorized and are recommended at least six months after your second dose if you fall into the following categories:
  • You SHOULD get a booster if you are 65 years or older; or you live in a long-term care setting; or you are age 50-64 and have underlying medical conditions; or you age 50-64 and are at increased risk of social inequity.
  • You MAY get a booster if you are age 18-49 and have underlying medical conditions  or are at increased risk of social inequity; or you are age 18-64 with no underlying medical conditions but are in an occupation which puts you at a higher risk of exposure to COVID.
  • Unlike Pfizer, the Moderna booster is half the strength as the original two shots. This is important because there is a difference between the Moderna booster versus the Moderna third shot. Boosters are given in individuals who have received a full series of the vaccine, but over time, their antibody levels fall and therefore need a “boost” to increase the antibodies again. On the other hand, third shots are recommended in individuals who have a compromised immune system, and therefore their two shots never get to an acceptable level of protection. They need that third shot to get their antibodies high enough to protect against COVID-19. These third shots are actually a full-size dose of the vaccine, not the half-size shot for boosters. Individuals who need this third shot include people who are actively being treated for cancer, have a diagnosed immune system deficiency, or are on immune suppressing drugs. If you are unsure if you fall into this category, please contact our office.
• Janssen/Johnson & Johnson: Boosters are now authorized and are recommended at least two months after your second dose for EVERYONE. The single shot vaccine does not appear to be as effective as the other two, so it is recommended that everyone get a booster shot.
• If you do not fall into any of the categories for receiving a booster but would still like to receive one, please contact the office and we will put you on our list. As before, we will likely have doses that will need to be thrown away at the end of the day if they are not given out. We can contact you to see if you want to get a booster dose instead of having that dose thrown away.

With regards to the “mix and match” of vaccines, there are some studies that show that using a different vaccine as a booster may lead to a higher increase in your antibodies. At this point, I would only recommend that if you got the Johnson & Johnson shot initially, you get a Pfizer or Moderna booster as your booster shot. Studies show that a second Johnson & Johnson shot does increase your antibodies, although not to the degree as a booster with the other two vaccines. Some individuals who got the Johnson & Johnson shot did so because they wanted to avoid the other two, and if that’s the case, then by all means get a second booster of the Johnson & Johnson vaccine. Also, there was a study showing that Moderna as a booster may lead to a numerically higher amount of antibody production compared to Pfizer, but it is unclear how significant this is. Therefore, if you had Pfizer for the first two shots, I am not recommending that you get Moderna over the Pfizer booster, but if you want Moderna as your booster, we will be able to give that to you as well. The vast majority of studies for boosters are with the same shot as the first two.
Finally, there has been some information about a new pill from Merck that has been shown to be helpful in treating COVID-19, but it is currently not approved. When more information is available, we will contact you again.

Influenza Vaccines:

Flu season is coming soon, and we are making preparations to vaccinate our patients. We had a light flu season last year because we were wearing masks all the time, but this year, with no mask mandates and everything being open, we will probably have many more cases of the flu. We feel the optimal time to get vaccinated in San Diego is late October or November because flu season here peaks around January, and by vaccinating at that time, 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 early 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. 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. Given a choice between the two of them, I would choose Flublok because it is not grown in eggs, which prevents possible mutations that can occur in egg-grown vaccines. 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. If you get your flu shot elsewhere, please let us know so we can document it, as we do try to monitor how many people get their flu shots annually. And if you are going to get a COVID-19 vaccine booster, know that it is OK to receive a COVID-19 vaccine together with a flu shot.

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 Tuesday, Wednesdays or Fridays, you can just stop by the office to get the vaccine. If you want to come in on Mondays or Thursdays, 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 COVID-19 Boosters

We finally have some guidelines on boosters, but things will continue to evolve. This is what we know right now:

• The advisory panel to the FDA gave recommendations on September 17 that certain groups of people should get a COVID-19 booster vaccine. This is just the advisory panel’s recommendation, and the full FDA, as well as the CDC, will still need to give their recommendations, which should occur within the next week or two.

• This recommendation is ONLY for the Pfizer vaccine, as that was the first one that was developed and come out to market. Moderna still has to get full FDA approval, and recommendations for their booster vaccine probably won’t happen until after they get full approval. Recommendations for the J&J vaccine will also come later.

• The proposed recommendation for the booster is for eight months after the second Pfizer shot. To be due for your booster today, you would have to have received your second Pfizer shot at the end of January.

• Who qualifies for a Pfizer booster shot, eight months after their second shot?
  • Individuals ages 65 and older
  • Individuals whose jobs put them at a higher risk of contracting COVID, including healthcare workers, first responders, teachers, and other groups
  • Individuals who are at high risk for complications from COVID. This has not been defined yet, and more clarity will occur when the FDA and CDC give their final approval.

• What if you are 64 years old and don’t meet the other criteria? You really should not worry because all 3 of the vaccines have still been shown to be excellent at preventing severe disease and death, even after the eight months. Over the next few months, they will continue to look at the data and decide if additional people should receive boosters.

• What are we doing in the office? We are still getting small shipments of Pfizer and Moderna vaccines and will be giving third shots in people that meet the appropriate criteria once they are announced. Even though it is not officially recommended to give third shots yet, if we have open vials of doses that will otherwise have be thrown away, we are still utilizing our list of people who want a third dose before the official recommendations come out.

• What should you do? If you had the Pfizer vaccine, feel like you meet the criteria for a booster shot, and want to get it at our office, PLEASE DO NOT CALL THE OFFICE. Instead, send a message through the portal or email [email protected] with the following information: your name, age, date of your second Pfizer vaccine, and whether you work in a high risk profession or have a high risk condition.

We will continue to provide you with more updates as information becomes available.

Recently, there has been a lot of information in the news about COVID-19 boosters in people that have already been fully vaccinated. There is some evidence that vaccines may start to lose full effectiveness after a few months, but there is other evidence that protection may last for years. With the current outbreak of the Delta variant, a fair number of people who have been fully vaccinated are still contracting COVID-19, but it is important to note that these breakthrough infections are almost always mild and do not lead to severe disease or death. These are my thoughts on COVID-19 vaccine boosters:

• First, I want to emphasize that people that have not yet been vaccinated should get their vaccine now. Many people feel that they are healthy and are unlikely to catch it. However, the Delta variant is much more transmissible and can still severely affect healthy individuals. I recently admitted somebody to the hospital who was a healthy unvaccinated 60-year-old man taking no medications. His daughter’s boyfriend’s boss came down with COVID, and his daughter and boyfriend both tested positive even though they had no symptoms. The patient unfortunately caught it from his daughter, got admitted to the hospital, and is now in the intensive care unit because of respiratory failure. Had he been vaccinated, he likely would NOT have required hospitalization.

• I agree with the World Health Organization that, with rare exception, people who are fully vaccinated do not need a booster at this time, and it is important that the rest of the world receive their first vaccine doses. Unvaccinated countries can lead to widespread transmission of the virus in their populations, causing more virus mutations and then potentially spreading to people who have fully been vaccinated. These mutated strains may not respond to the current treatments for COVID-19. To this end, the US has already shipped more than 110 million doses to other countries to aid in the worldwide vaccination effort.

• We are still conducting studies to see if certain population groups would benefit from a booster shot, and once the recommendations come out, those people would be eligible.

• If you have been fully vaccinated, and you do end up contracting COVID-19, you have a less than 0.01% chance of being hospitalized from it, and less than 0.001% chance of dying from it.

• Because vaccinated people can still catch and transmit COVID-19, I recommend that everyone who has cold-like symptoms or unexplained fevers to still get tested, either through the traditional testing sites, or through at-home antigen self-testing (click the COVID-19 tab above to read more).

• Likewise, if you have cold-like symptoms or “allergy” symptoms, please do not come into our office for your regularly scheduled appointment without calling us first.

Having said all this, is also true that there have been over a million doses of COVID-19 vaccines that have gone to waste in the US because they have expired or not enough people are choosing to get them. Our office is currently receiving only excess vaccine doses from health facilities that cannot use them, and we are not ordering them directly from the government. From my standpoint, instead of letting these doses go to waste when they expire, I would rather have someone receive them as a booster shot, even before we have definitive evidence that they are beneficial. I feel that as long as there is a chance that a booster shot will be beneficial, and any risks from the shot are negligible, it would be worth putting that vaccine in someone’s arms as opposed to in the trash can. To that end, we are now accumulating a list of people who are interested in receiving a booster shot. Because the data have not come back yet, we cannot say if it would be better to get the same manufacturer as your first vaccine or a different one. We will prioritize individuals over age 65 and those on immunosuppressive medications first, as these individuals are likely going to be the first that will receive approval for a booster shot if and when it is needed. If you are interested, please send us a message through the portal or email us at  [email protected] and let us know your name, phone number, and which vaccines you are willing to come in for.