A Happy New Year
Published Dec 27, 2022 12:05 am
CLINICAL MATTERS
DR. EDSEL SALVANA
If global trends continue, it will definitely be a happy new year in 2023 as the end of the pandemic is at hand. Citing the continued decline in cases and deaths, World Health Organization (WHO) director general Tedros Ghebreyesus is hopeful that the emergency phase of the Covid-19 pandemic will end next year. This could be as soon as January when the WHO meets to discuss whether parameters for endemicity have been reached. This will confirm what we have been seeing on the ground for some time now. Covid-19 has been transformed from a deadly disease to one that is much less potent and with a much less societal impact, thanks to vaccines and effective treatments.
The last three years have been surreal. Even now, many of us struggle to process how much the world changed, especially during the early parts of the pandemic. Shutting down mobility in communities was unnatural, but a necessary evil in the face of a killer we did not completely understand. As we learned more about preventing and treating infections, we began to slowly roll back restrictions. When the vaccines arrived within an extraordinarily quick framework, many of us thought it was the beginning of the end for the virus. Unfortunately, SARS-CoV-2 found a second wind, mutating into immune-evading variants and launching new waves of infection.
The rise of Delta was perhaps the lowest point for everyone. Faced with a deadlier and more contagious virus, the healthcare system was threatened anew. We scrambled to deploy the vaccines quickly. After the onslaught of Delta, the vaccination campaign picked up steam and when Omicron arrived, it became clear that Covid-19 was losing its bite. Despite multiple false alarms and prophets of doom saying the next variant was going to be the worst one, Covid-19 cases remained manageable. Vaccines continue to protect against severe disease, and bivalent vaccines are on the way.
Data on the clinical efficacy of bivalent vaccines as boosters is now slowly trickling in. When bivalent boosters were first approved and deployed, the only proof of efficacy was improved neutralizing antibody activity against the new variants compared to the monovalent (old vaccine) boosters. It was also difficult to make firm conclusions on efficacy because everyone had either already been at least one vaccine dose, or had natural infection, or both. Comparing a new intervention with whatever baseline immunity there was meant that the difference in protection would not look as big as at the start of the pandemic. This was because everyone was unvaccinated and did not have previous infection that confers some protection. In addition, the variants of concern are now much more transmissible than the original viruses and so expecting levels of protection against infection at par with the original vaccines is no longer realistic.
Despite these limitations, the newest data from the US Centers for Disease Control clearly show that the new bivalent vaccines add an additional 50 percent or more protection. This is quite significant since it answers important questions on whether the favorable neutralizing antibody data would translate into clinical protection. It most certainly does. This validates the idea of adding subvariant mRNA to the mix of boosters for better protection and bodes well for strategies to improve vaccine efficacy.
One major question is whether we will need periodic boosting. Based on the latest data, the population most likely to benefit from bivalent boosters is still the vulnerable population, particularly the elderly and those with comorbid conditions. Even with a full set of vaccination and one or two monovalent boosters, there is still value in getting an up-to-date bivalent vaccine. The residual risk of severe Covid-19, albeit a 10th of the original risk prior to vaccination, is still big enough to warrant further protection in this risk group. The need for further boosters will likely be determined by multiple factors, including the degree of community transmission and the emergence of new variants. In younger populations and the general public, a single bivalent booster will probably be in enough for long-lasting protection, barring the emergence of a new, significantly immune escaping variant.
The bivalent vaccines will probably arrive in the Philippines in the first quarter of 2023. In the meantime, what is the best strategy for boosting?
If you are in the elderly population, the current recommendation is to get two boosters on top of the original primary series. Beyond two monovalent boosters, there is no evidence that a third monovalent booster adds substantial protection. The bivalent vaccine will likely be given at least three months from the last booster, and the vulnerable population will be prioritized for shots.
If you are not in the vulnerable population, the primary series plus only one monovalent booster is recommended. If you haven’t gotten your first booster yet and it has been more than three months from the second dose of the primary series, do not wait for the bivalent booster. Get a monovalent booster now.
If you have already received one monovalent booster dose and you are not in the vulnerable population, it is ok to wait for the bivalent booster even if it has been more than three months. The data for a second monovalent booster in the low-risk population isn’t compelling, but healthcare workers are allowed to access them anyway. Personally, I never took a second monovalent booster even if I qualified as a healthcare worker since the data was not convincing enough for me. I got my bivalent booster in the US in October 2022 when I was there for a convention and so far, so good. I have not gotten a new Covid-19 infection even if BA.5 has already taken over locally along with other Omicron sublineages. For those who got two monovalent boosters anyway, you would probably still qualify for a bivalent booster once three months have passed from the last dose.
There is so much to look forward to in 2023 as the world opens up again and Covid-19 becomes endemic. It is important to keep the lessons of the past in mind, and even now it is probably still smart to use your mask, especially in crowded gatherings. The new normal is upon us, and it is up to each of us to ensure it is a better one.
DR. EDSEL SALVANA
If global trends continue, it will definitely be a happy new year in 2023 as the end of the pandemic is at hand. Citing the continued decline in cases and deaths, World Health Organization (WHO) director general Tedros Ghebreyesus is hopeful that the emergency phase of the Covid-19 pandemic will end next year. This could be as soon as January when the WHO meets to discuss whether parameters for endemicity have been reached. This will confirm what we have been seeing on the ground for some time now. Covid-19 has been transformed from a deadly disease to one that is much less potent and with a much less societal impact, thanks to vaccines and effective treatments.
The last three years have been surreal. Even now, many of us struggle to process how much the world changed, especially during the early parts of the pandemic. Shutting down mobility in communities was unnatural, but a necessary evil in the face of a killer we did not completely understand. As we learned more about preventing and treating infections, we began to slowly roll back restrictions. When the vaccines arrived within an extraordinarily quick framework, many of us thought it was the beginning of the end for the virus. Unfortunately, SARS-CoV-2 found a second wind, mutating into immune-evading variants and launching new waves of infection.
The rise of Delta was perhaps the lowest point for everyone. Faced with a deadlier and more contagious virus, the healthcare system was threatened anew. We scrambled to deploy the vaccines quickly. After the onslaught of Delta, the vaccination campaign picked up steam and when Omicron arrived, it became clear that Covid-19 was losing its bite. Despite multiple false alarms and prophets of doom saying the next variant was going to be the worst one, Covid-19 cases remained manageable. Vaccines continue to protect against severe disease, and bivalent vaccines are on the way.
Data on the clinical efficacy of bivalent vaccines as boosters is now slowly trickling in. When bivalent boosters were first approved and deployed, the only proof of efficacy was improved neutralizing antibody activity against the new variants compared to the monovalent (old vaccine) boosters. It was also difficult to make firm conclusions on efficacy because everyone had either already been at least one vaccine dose, or had natural infection, or both. Comparing a new intervention with whatever baseline immunity there was meant that the difference in protection would not look as big as at the start of the pandemic. This was because everyone was unvaccinated and did not have previous infection that confers some protection. In addition, the variants of concern are now much more transmissible than the original viruses and so expecting levels of protection against infection at par with the original vaccines is no longer realistic.
Despite these limitations, the newest data from the US Centers for Disease Control clearly show that the new bivalent vaccines add an additional 50 percent or more protection. This is quite significant since it answers important questions on whether the favorable neutralizing antibody data would translate into clinical protection. It most certainly does. This validates the idea of adding subvariant mRNA to the mix of boosters for better protection and bodes well for strategies to improve vaccine efficacy.
One major question is whether we will need periodic boosting. Based on the latest data, the population most likely to benefit from bivalent boosters is still the vulnerable population, particularly the elderly and those with comorbid conditions. Even with a full set of vaccination and one or two monovalent boosters, there is still value in getting an up-to-date bivalent vaccine. The residual risk of severe Covid-19, albeit a 10th of the original risk prior to vaccination, is still big enough to warrant further protection in this risk group. The need for further boosters will likely be determined by multiple factors, including the degree of community transmission and the emergence of new variants. In younger populations and the general public, a single bivalent booster will probably be in enough for long-lasting protection, barring the emergence of a new, significantly immune escaping variant.
The bivalent vaccines will probably arrive in the Philippines in the first quarter of 2023. In the meantime, what is the best strategy for boosting?
If you are in the elderly population, the current recommendation is to get two boosters on top of the original primary series. Beyond two monovalent boosters, there is no evidence that a third monovalent booster adds substantial protection. The bivalent vaccine will likely be given at least three months from the last booster, and the vulnerable population will be prioritized for shots.
If you are not in the vulnerable population, the primary series plus only one monovalent booster is recommended. If you haven’t gotten your first booster yet and it has been more than three months from the second dose of the primary series, do not wait for the bivalent booster. Get a monovalent booster now.
If you have already received one monovalent booster dose and you are not in the vulnerable population, it is ok to wait for the bivalent booster even if it has been more than three months. The data for a second monovalent booster in the low-risk population isn’t compelling, but healthcare workers are allowed to access them anyway. Personally, I never took a second monovalent booster even if I qualified as a healthcare worker since the data was not convincing enough for me. I got my bivalent booster in the US in October 2022 when I was there for a convention and so far, so good. I have not gotten a new Covid-19 infection even if BA.5 has already taken over locally along with other Omicron sublineages. For those who got two monovalent boosters anyway, you would probably still qualify for a bivalent booster once three months have passed from the last dose.
There is so much to look forward to in 2023 as the world opens up again and Covid-19 becomes endemic. It is important to keep the lessons of the past in mind, and even now it is probably still smart to use your mask, especially in crowded gatherings. The new normal is upon us, and it is up to each of us to ensure it is a better one.