COVID-19 Updates

Changing COVID-19 recommendations means the science is working

Are Moderna and J&J getting a booster shot? Should tell my patients to wait until their children turn 12 so they can get the bigger vaccine dose? Learn that and more in this Mayo Clinic podcast.
November 2, 2021
Guest: Gregory A. Poland, MD ; Host: Halena M. Gazelka, MD

Dr. Halena M. Gazelka: Welcome everyone to Mayo Clinic Q&A. I'm Dr. Holly Gazelka. We're recording this podcast on Monday, October 18th, 2021. Here with us to discuss today is Dr. Greg Poland. Thanks for being here again today, Greg. 

Dr. Greg Poland: Yes, of course. Good morning and happy Monday. 

Dr. Halena M. Gazelka: Tell us what's been happening with all these meetings and advisory panels. It's hard for us all to keep up. 


Dr. Greg Poland: So, there were two, all-day meetings this past week. And basically what the committee heard were the data supporting the notion of a booster dose for Moderna and J&J. 

And then the second item was about so-called “mix and match” – who should get what kind of vaccine? Now, I want to go through this a bit slowly so people don't get confused. Previously, the recommendation was made for the third dose of Pfizer vaccine for people who were moderate to severely immunocompromised. So, if you're moderate to severely immunocompromised in reality, your series is three doses. For everybody else, it's a series of two doses. 

And, if you fit into certain categories, the other point is that very likely the Moderna booster will be half the dose that you got in your primary series. So, in other words, not 100 micrograms, but 50 micrograms. J&J and Pfizer will stay the same. 


What happened this past week is that the committee voted on both questions unanimously in favor of authorizing a Moderna booster and J&J booster. Now, here's what has to happen. The FDA takes that advisory committee’s recommendation under advisement. They will issue a recommendation this week. It will now go to the CDC to what's called the ACIP – Advisory Committee on Immunization Practices – and they will actually implement and approve that. 


So, what do I expect will happen? I expect that we will see that recommendation voted favorably upon. And it's pretty simple. 

If you are over the age of 65, you should be offered a booster. If you are over the age of 18 and in a long-term care setting, you should be offered a booster. If you are greater than 18 years old and have underlying medical problems, you should be offered the booster. If you're over 18 and work in a high-risk setting, you may be offered the booster. And if you're over 18 and living in a high-risk setting (for example, a home prison), then you also may be offered that vaccine. 

So, really, at this point, it's functionally almost everybody over the age of 18 who's at elevated risk. You and I being in health care. It's first responders. It's teachers. Those are high-risk settings, as we know, as kids have gone back to school. On that same note, what will happen toward the end of this month will be another committee meeting about extending the Pfizer vaccine down to age five. So, a lot happening. 


One of the big questions that come up is this mix and match. And let me kind of summarize that data. I think this is my belief we will move to the point where J&J is the two-dose series, just like the RNA vaccines. 

If you got the J&J vaccine and you get a J&J booster, your antibodies go up about fourfold. If you got the J&J as your primary dose and you get Pfizer, your antibodies go up 35 fold. If you got the J&J as your initial dose and got them Moderna booster, your antibodies go up 76 fold. Now, those are impressive numbers. But even the second J&J vaccine is tremendously effective. 

And again, in transparency, none of the studies that are being brought forward to talk about booster doses measured T-cell immunity, which is a major arm of immunity. So, we're kind of basing all of this on antibody level, which we believe is likely to turn out to be a correlate of protection. 


There's one other point that likely will not occur to people immediately. A very high-risk group and we've talked a bit about it in the past, are pregnant women. Even though they are younger, they don't have any perhaps underlying medical conditions. They're not in a high-risk setting or a high-risk workplace. 

They do get a booster because the risk when you're pregnant is so high – about a 70 fold increased risk of death even for a healthy pregnant woman. So, a pregnant woman who's had two doses, let's say, of an RNA vaccine does get a booster dose if it's been six or more months. A lot of information there. 

Dr. Halena M. Gazelka: It's a lot of information, and I appreciate you mentioning the pregnancy because have multiple listener questions on that very topic. And speaking of listener questions, Greg, I have a number of them for you today. 

So, I think you answered this question earlier. But just to clarify for this listener, are booster shots the exact same vaccine as what was given earlier? 


Dr. Greg Poland: No, you're exactly right, Helene. If you get a J&J booster, it is identical to your first shot. If you get a Pfizer booster, it is identical to the original Pfizer vaccine. If you get them during a booster, it is identical in composition, but different in dose instead of 100 micrograms. You'll get half that, 50 micrograms. 

And just to make it a little more complicated, when we get to immunizing children 5 to 11, it will be a third of the normal Pfizer dose when we get to six months, up to four years. It'll be a tenth of the normal Pfizer dose. So, that'll have to be kept in mind for the ones administering the vaccine. But the composition of the vaccine is identical across those doses, and that really shouldn't be surprising. 

Dr. Halena M. Gazelka: All right. Next question. This individual states that their 84-year-old mother is frail but not immunocompromised. They've been trying to encourage her to consider a booster. She has heard from a friend that the booster gave them COVID. Is that possible? 


Dr. Greg Poland: That's impossible. And just to correct two misperceptions there, even an otherwise healthy, non-frail 84-year-old is, in essence, immunocompromised. They have what we call immunosenescence. Their immune system has aged to the point where they don't have the same immune response and are at increased risk. And we use that as a cutoff. 

It saddens me to say since I've now joined this club, anybody over the age of 65. So, she absolutely should have a booster, but it is impossible to get COVID from the vaccine. All of the vaccines available here in the U.S. contain one tiny protein from the virus. It is not a live virus. It's sort of like taking a pad and just taking the little clicker ballpoint part of it and saying that's the vaccine. It's not the pen you couldn't write with it, just like you can't get infected with the virus or get COVID from the vaccine. 

Dr. Halena M. Gazelka: You answered this a little bit earlier as well, but this individual is thinking about receiving a booster vaccination while pregnant. She received the Moderna vaccine and now is wondering if a booster is recommended, should she get the booster prior to her delivery?


Dr. Greg Poland: If it has been six or more months since she completed her primary series, I don't think we can go over this enough. It's so important. I know pregnant women are still running half marathons. They are healthy. But because they’re pregnant, it increases their risk for pulmonary infection and complications such as blood clotting. And, as we mentioned, the risk of death is seven times higher. 

A woman, her exact same age and health, but who is not pregnant, if it's been six or more months, they do get a booster. Now, if it's Moderna, they'll get a booster. That's half the dose of their primary series. But really important that they get that booster. 

Dr. Halena M. Gazelka: All right. Our next listener says they have kept their children home from school so that they will not develop COVID once they are vaccinated. Would it be safe to send them to school for the rest of the school year? 


Dr. Greg Poland: It's a good question, and the way I want to answer it is this way. There's no such thing as safe. I mean, fundamentally, I think we have to acknowledge that there's no such thing as safe. There is safer and being vaccinated is safer than not being vaccinated. 

My personal opinion is the best place for kids is in school. All the activities that occur – the learning, the group, learning the socialization – that's important. Whether they're in home school or public school or private school. And so, yes, being immunized offers them just fantastic odds of either not getting infected or if they got infected, being asymptomatic or, at worst, mild disease. So very much worth immunization. 

Now, I would have a discussion with your health care provider based on any medical conditions that the child has and any risks associated with the vaccine. As we have always talked about, there are risks to the vaccines, but they occur a handful of times out of a million versus the risks of disease. And so you and your health care provider can best make that determination about benefit and risk. 

Dr. Halena M. Gazelka: All right, this next question is about vaccine dosing. This individual has an 11-year-old daughter who weighs an adult weight, about 140 lbs. She says that, if the vaccine is approved for under age 12, she would get a smaller dose of the vaccine, as you discussed. If they were to wait three more months until her birthday in January, she would get a larger dose of the vaccine because she would be 12 years old. Would you say that she should wait and get the larger dose of the vaccine or accept what could be given now? 


Dr. Greg Poland: These are tough questions. Again, that balance of risks and benefits regardless of weight. This recommendation is being made by age, and so we're obligated to follow the prophet provisions of the EU way. That's one point. 

The second point is, and I want to say this carefully: more is not necessarily better. If she were to get her dose, whether her antibodies went up 20 fold or 40 fold, I don't think matters. The point is that she'll be protected. You're so far above the level of protection, assuming an otherwise normal healthy child that I think to go against the EU way and try to dose somebody because you think you know more. I think that's shaky scientific ground, and it's definitely shaky legal ground. 

Dr. Halena M. Gazelka: And then I think of the months of being inside. If this individual is attending school in the wintertime, then those extra months of being vaccinated are probably quite important. 

Dr. Greg Poland: Oh, yes. And I think the parent that wrote in is thinking wisely as our listeners always in asking about that and asking questions and being skeptical and looking for answers, I think that's great. I am concerned that, as we see around the U.S., numbers are dropping now along the north. They're not dropping, they're rising. 


When you look at North Dakota, Montana, Idaho, Alaska, Minnesota is up 12 percent. And we're going to see that we've seen this before. We had really large high numbers that started dropping in late summer, only to see the numbers pick back up as people go indoors. There's cooler, wetter weather, and the virus survives better. So now, I think, is a very opportune time to get those boosters and try to prevent that happening, particularly with the holidays coming. 

Dr. Halena M. Gazelka: Mm-Hmm. That's a very good point. Well, Greg, you gave us a lot of information today. I have reached the end of the mailbag. Do you have anything else you'd like to share with us today? 


Dr. Greg Poland: You know, I think that there's going to be a lot of information. Social media is not always going to get it right. Please go to credible sources. A lot is changing. The fact that recommendations are changing is not evidence that people don't know what they're doing. It's evidence that they do know what they're doing, and they're paying close attention to new data that's coming along and then adjusting recommendations based on that. 

For example, we heard just superb presentations. Israel is ahead of us in terms of the use of boosters, despite the fact that they had such high levels of immunization. They were seeing breakthrough cases. They embarked on their booster program and reduced cases by over 90 percent. Now, that's the power of these boosters over time. 

Of course, when the two-dose recommendation was made, we didn't have years of experience with this virus to say, “Oh, well, everybody needs a booster at six months.” We're just learning that now as we get to this six, seven, and eight months since people have been immunized. So, I do urge people to take these recommendations for boosters very seriously.

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