On clarification on "cost effective." Katelyn said correctly that the vaccines given to those 65+ annually are cost effective. However, that does not mean that the vaccines would cost less than the prevented hospitalization. That is "cost saving," a special subset of cost-effective. The ACIP reported that a single dose of COVID vaccination annually for those over age 65 was cost saving last fall, but "only" cost effective (Cost of $11K per QALY) with this Spring's evaluation.
We generally consider interventions cost effective if they cost less than $50K (or $100K or $150K) per Quality Adjusted Life Year (QALY) saved. VERY few things within medical care delivery are cost saving (traditional childhood vaccines, birth control and abortion, as well as flu shots for those over 55, palliative care and smoking cessation. But not much else!). So it's pretty amazing that the these vaccinations are cost effective - though they are not cost saving.
Again, thanks to YLE for all that you do to keep us informed!
QALY seems like maybe not broad enough of a metric. E.g. a $200 out-of-pocket vaccine that prevented you from missing one day of work would be worth it for many people even if it only infinitesimally affected the remaining quality/length of my life. Employers would also get a financial benefit from having a vaccinated workforce. (I know vaccines don't necessarily prevent infections, but it presumably(?) reduces them on an aggregate level, if only because vaccinated people recover more rapidly.) This was true pre-pandemic, where many employers would have flu vaccine drives at office buildings, though that was for recommended yearly doses, not "bonus" ones.
I guess if the duration of illness was counted against QALY, that would allay this concern (so e.g. if an extra dose conferred a 10% chance of avoiding being sick for 5 days at $150K/year, that would work out to something like a $205 benefit). Does being sick with ordinary COVID symptoms count against QALY?
You had me at hello with this: "The vast majority (95% of adults) were not up-to-date on their annual Covid-19 vaccine."
Followed by that lovely chart showing only 2-5% of hospitalizations across ALL age groups had received the XBB monovalent vaccine this fall.
Another commenter astutely quoted the vaccine durability looks pretty good through 119 days, but I'm not sure we can say not waning yet, as we are now another 60+days since the end of that period.
With Covid being a systemic disease, and my primary care priority of preventing complications, increased CV risks, long Covid, and problems well beyond the most dire data points of hospitalization and death... I'll be giving the spring boost a thumbs up for my peeps.
With so few people up to date on boosters I don't see a downside to recommending a "spring vaccine". I'm going to discuss getting one with my PCP on my next visit (she didn't bring it up in my most recent visit last month).
The FDA should streamline approval of RNA vaccines against new variants and encourage manufacturers to produce them.
BARDA should focus more on development of universal vaccines for COVID and flu.
Congress should approve dedicated funding for these projects.
Dr. McCormick: I see you’re differing from Dr. Jetelina’s assessment here: “I’m not convinced that most people over 65 need a spring vaccine. I will be recommending a spring vaccine to my family members in nursing homes (they are over 90 years old) or those who have multiple comorbidities, like heart disease. I don’t think they need to run to get it, but there will be a small benefit, given that we have multiple waves a year and their T cells (immune memory) are weak against Covid-19.” Do I assume you will be uniformly encouraging your over 65s without multiple comorbidities to get the spring vax, despite what Dr. Jetelina sees as only a small benefit? If so, would appreciate your thinking on that.
Hi Susan - I don’t want to contradict anything here, I think the information presented is great. I just have a lot of confidence in the risk/benefit tilting toward benefit for the higher risk folks, and probably the less higher risk people if we consider that every Covid infection is another opportunity for damage under the hood, and this XBB vaccine reduced Covid incidence among recipients by 50% this year. COVID never seems to die or fade much lately, and the death toll itself is mind numbing.
I’m sticking with the safety statements of the CDC, as a lot of people have worked really hard to assure us of safety - and unknown long term risks of repeated vaccination seem to pale in comparison to long term risks of repeated infections - which we have proven we can reduce with vaccines, q6 months if necessary for the higher risk. And other behaviors which are increasingly hard to maintain for social creatures.
I’ll try to do a post about this! I like this page from CDC in the meantime:
My mom is 100, in her own home ( but home bound) in a major city, and we have been trying for months to get her a vaccine. From the hospice, no. From her delivery pharmacy, no. Access for the frail elderly and disabled is terrible, and yet these are the people who need it most.
At my own pharmacy, there have been signs on the doors for months, saying “ we have no Covid vaccine.”
This access issue is another reason even older people aren’t getting vaccinated.
About the same. Is it better? We don't know yet. I have been trying to find it, personally, because I got Novavax. The sample is just so small, that there is a lot of uncertainty around estimates. I will keep my eyes peeled.
Hubby fully vaxxed and boosted with Novavax in Dec, I boosted with Pfizer in November. Both of us got Covid Feb 2 while traveling. Very sick, almost identical symptoms, still lingering cough and some fatigue. (First time with Covid, no comorbidities)
I don’t remember which study but isn’t there strong evidence that Novavax is better than mRNA at preventing lower lung infection? I have also read (but forget the source) that if you took Novavax and later get an infection, you are less likely to infect others.
My family had this debate with the doctors / pharmacies last year too. Problem is -- our doctor agreed with the need, but we couldn't get the medical group or the retail pharmacies to deviate from the black-and-white parameters. One family member with Type 2 diabetes had to argue with a retail pharmacy and pull up definition of "immunocompromised" on the phone before he finally got a shot.
Very frustrating especially when there wasn't a shortage, and the medical community was lamenting low vaccination rates.
You said that “ I’m not convinced that most people over 65 need a spring vaccine.” If you want to educate people and have them take your advice, show the data to support this opinion so people can make an informed judgement.
Thanks for your feedback! I peppered the reasons throughout this post, but I could have summarized them better. Writing Cliff notes in real time is... challenging. There are a few reasons I think this: 1. The vast majority of people in the hospital and dying aren't getting *one* shot a year. Only 5% in the hospital had their fall vaccine, and among those, the majority are those with multiple comorbidities and severely immunocompromised. 2. no observation data presented showed two shots a year are more beneficial than one shot a year. If we recommend an intervention to the Americans, we must have strong evidence. There has been one study (not presented at ACIP) that shows there is very little benefit, actually. 3. There is little evidence of waning thus far from the fall vaccines. 4. Given what we know about immune system memory, multiple comorbidities and age are the biggest problem.
“Age and comorbities”! Right - over 30 million Americans are over age 65 and an awful lot of us have one or more “comorbidites”. Not having a “Should” rather than a “May” means working very hard to find an MD who will do it - not to mention drug chains! Get real and rediscover your empathy. You’ve spent too much time with the “responsible” public health care bureaucrats.
But are hospitalizations all we care about. Two of my first degree relatives had over 6 months of heart and lung issues post covid. I'm still masking and trying to avoid it, but just because someone isn't hospitalized doesn't mean there aren't serious health complications that will cost us in so many ways. I'm ready to cry because no one seems to care about at risk individuals anymore.
Thanks for the update. If a previous infection should count like a vaccine, it seems obvious that one of the major reasons people aren’t getting vaccinated is because they recently had Covid. This reason doesn’t show up in the CDC survey results, perhaps because of how the survey was designed. Many people I know got Covid in late summer/early fall, even before back-to-school.
What this means is we need to get updated boosters out sooner - not September/October.
I think a big reason the numbers are down for getting vaccinated is that it became commercialized and it cost many. I can give you many examples here in Maine where if the vaccine continues to be free folks would have gotten it
They presented some data on this. Let me find it really quick, but I was susprised how much cost wasn't a factor for the *general population*. It is driving inequities though
Thank you. From a public health perspective, can you explain why the ACIP is not recommending the spring vaccine for those who have comorbidities / are immunocompromised, even if they have not reached the age of 65? And what is the evidence that supports drawing the line at 65 instead of, say, 55 or 60?
Probably because Medicare kicks in at 65 and those under age 65 may have to pay OOP unless their insurance company covers it. Wouldn’t surprise me if there was a lot of insurance company influence in setting the age to keep costs down. Welcome to American healthcare politics.
Just a reminder on why ACIP might have had to issue a pro forma "should" - because of its statutory role relative to the Affordable Care Act. The only way to guarantee that ACA plans cover vaccines without cost sharing is an affirmative recommendation from ACIP. If you want a compelling reason for ACIP to use "should" versus "may" - there you have it.
Thank you as always for your ACIP Cliff notes, I always look forward to reading your newsletter. I've been run COVID19 vaccine clinics in the metro Boston area since vaccines rolled out in 2021. The biggest difference (we found) between the current 2023-2024 COVID19 immunization season and prior years is the privatization of vaccines and overall cost. While the recommendations mean insurance companies "have to" reimburse for the vaccine, not all insurance companies cover the cost (HMO's out of network won't). The out of pocket cost for the COVID19 vaccine is $170-$190. For those under insured or without insurance, finding a pharmacy that participates in the Bridge Program is challenging. I wish our gov't would cover the full cost of vaccines, this would be so helpful for so many. Thank you again!! p.s. I agree stronger language "should" might be more impactful this spring.
I’ll add my bit regarding “may” versus “should”. The real life consequences of the wording for who should get the adult RSV vaccine resulted in some medical groups requiring (read delaying) vaccinating people in the target group. This affected family members and friends of mine. So I’m all for “should” in the over 65 group.
My husband and I (79 and 78) have had every COVID vaccine dose offered including last fall just before leaving for a tour of Slovenia/Croatia in October. We both got COVID for the first time with symptoms starting two days apart. It was like a very bad cold (him) or flu (me). Both had fevers for 2-3 days. We are traveling to the UK this June. Soliciting opinions on getting another dose in maybe April? Both of us had lingering fatigue and I think it may be persisting for me.
With the persistent fatigue I would ask your doctor to check a) a full iron panel and b) a full thyroid panel that includes free T3. Both low iron and low FT3 can cause fatigue type symptoms.
While looking at the impact on hospitalizations is important, it ignores the big issue of long covid. It's been shown that vaccines reduce the risk of long covid. Given the safety of these vaccines for the vast majority, an updated shot every 6 months for the vast majority (including those under 65) would go a long way to prevent more long-covid cases and disability as covid continues to evolve. It would also reduce missed school and work days as it reduces the risk of transmission and severity of illness among those not hospitalized. Hospitalization is not the only important outcome to consider, right?
I have asthma and even colds mess me up for a while. They don't send me to the hospital but they are disruptive. Anything that reduces the amount of time I spend coughing would be great, so I would happily get a shot every 6 months if they let me (and my kids too, as I especially want to reduce their risk of long-covid).
"Americans over the age of 65 should receive a second dose of the booster shot recommended in September, a Centers for Disease Control and Prevention advisory panel voted Wednesday, noting that the extra protection has likely already begun to wane."
As always, YLE summaries are the best!
On clarification on "cost effective." Katelyn said correctly that the vaccines given to those 65+ annually are cost effective. However, that does not mean that the vaccines would cost less than the prevented hospitalization. That is "cost saving," a special subset of cost-effective. The ACIP reported that a single dose of COVID vaccination annually for those over age 65 was cost saving last fall, but "only" cost effective (Cost of $11K per QALY) with this Spring's evaluation.
We generally consider interventions cost effective if they cost less than $50K (or $100K or $150K) per Quality Adjusted Life Year (QALY) saved. VERY few things within medical care delivery are cost saving (traditional childhood vaccines, birth control and abortion, as well as flu shots for those over 55, palliative care and smoking cessation. But not much else!). So it's pretty amazing that the these vaccinations are cost effective - though they are not cost saving.
Again, thanks to YLE for all that you do to keep us informed!
Ah, thanks for providing more context! I, selfishly, learned a thing or two :)
QALY seems like maybe not broad enough of a metric. E.g. a $200 out-of-pocket vaccine that prevented you from missing one day of work would be worth it for many people even if it only infinitesimally affected the remaining quality/length of my life. Employers would also get a financial benefit from having a vaccinated workforce. (I know vaccines don't necessarily prevent infections, but it presumably(?) reduces them on an aggregate level, if only because vaccinated people recover more rapidly.) This was true pre-pandemic, where many employers would have flu vaccine drives at office buildings, though that was for recommended yearly doses, not "bonus" ones.
I guess if the duration of illness was counted against QALY, that would allay this concern (so e.g. if an extra dose conferred a 10% chance of avoiding being sick for 5 days at $150K/year, that would work out to something like a $205 benefit). Does being sick with ordinary COVID symptoms count against QALY?
Thanks for the cliff notes!
You had me at hello with this: "The vast majority (95% of adults) were not up-to-date on their annual Covid-19 vaccine."
Followed by that lovely chart showing only 2-5% of hospitalizations across ALL age groups had received the XBB monovalent vaccine this fall.
Another commenter astutely quoted the vaccine durability looks pretty good through 119 days, but I'm not sure we can say not waning yet, as we are now another 60+days since the end of that period.
With Covid being a systemic disease, and my primary care priority of preventing complications, increased CV risks, long Covid, and problems well beyond the most dire data points of hospitalization and death... I'll be giving the spring boost a thumbs up for my peeps.
With so few people up to date on boosters I don't see a downside to recommending a "spring vaccine". I'm going to discuss getting one with my PCP on my next visit (she didn't bring it up in my most recent visit last month).
The FDA should streamline approval of RNA vaccines against new variants and encourage manufacturers to produce them.
BARDA should focus more on development of universal vaccines for COVID and flu.
Congress should approve dedicated funding for these projects.
Dr. McCormick: I see you’re differing from Dr. Jetelina’s assessment here: “I’m not convinced that most people over 65 need a spring vaccine. I will be recommending a spring vaccine to my family members in nursing homes (they are over 90 years old) or those who have multiple comorbidities, like heart disease. I don’t think they need to run to get it, but there will be a small benefit, given that we have multiple waves a year and their T cells (immune memory) are weak against Covid-19.” Do I assume you will be uniformly encouraging your over 65s without multiple comorbidities to get the spring vax, despite what Dr. Jetelina sees as only a small benefit? If so, would appreciate your thinking on that.
Hi Susan - I don’t want to contradict anything here, I think the information presented is great. I just have a lot of confidence in the risk/benefit tilting toward benefit for the higher risk folks, and probably the less higher risk people if we consider that every Covid infection is another opportunity for damage under the hood, and this XBB vaccine reduced Covid incidence among recipients by 50% this year. COVID never seems to die or fade much lately, and the death toll itself is mind numbing.
I’m sticking with the safety statements of the CDC, as a lot of people have worked really hard to assure us of safety - and unknown long term risks of repeated vaccination seem to pale in comparison to long term risks of repeated infections - which we have proven we can reduce with vaccines, q6 months if necessary for the higher risk. And other behaviors which are increasingly hard to maintain for social creatures.
I’ll try to do a post about this! I like this page from CDC in the meantime:
https://www.cdc.gov/coronavirus/2019-ncov/vaccines/safety/adverse-events.html
Very thoughtful—and ai look forward to your post, as well. Thank you!
Dr. Jetelina,
My mom is 100, in her own home ( but home bound) in a major city, and we have been trying for months to get her a vaccine. From the hospice, no. From her delivery pharmacy, no. Access for the frail elderly and disabled is terrible, and yet these are the people who need it most.
At my own pharmacy, there have been signs on the doors for months, saying “ we have no Covid vaccine.”
This access issue is another reason even older people aren’t getting vaccinated.
Have you tried the local health department? We give Covid vaccines to homebound people in our community.
Thanks for the suggestion. We can try.
See my most recent comment. We are finding no help at all.
Consider contacting Pfizer directly…?
Why should it be this hard???
It shouldn’t. But our current Congress considers spending on health care to be a loser.
Hi YLE! Can you tell us how Novavax compares to the mRNA vaccines in terms of VE and durability? Thanks!
About the same. Is it better? We don't know yet. I have been trying to find it, personally, because I got Novavax. The sample is just so small, that there is a lot of uncertainty around estimates. I will keep my eyes peeled.
I second Jennifer’s curiosity!
Hubby fully vaxxed and boosted with Novavax in Dec, I boosted with Pfizer in November. Both of us got Covid Feb 2 while traveling. Very sick, almost identical symptoms, still lingering cough and some fatigue. (First time with Covid, no comorbidities)
I don’t remember which study but isn’t there strong evidence that Novavax is better than mRNA at preventing lower lung infection? I have also read (but forget the source) that if you took Novavax and later get an infection, you are less likely to infect others.
Thank you!
Is there any indication that those under age 65 with health considerations like being immunocompromised can get the vaccine if a doctor recommends it?
My family had this debate with the doctors / pharmacies last year too. Problem is -- our doctor agreed with the need, but we couldn't get the medical group or the retail pharmacies to deviate from the black-and-white parameters. One family member with Type 2 diabetes had to argue with a retail pharmacy and pull up definition of "immunocompromised" on the phone before he finally got a shot.
Very frustrating especially when there wasn't a shortage, and the medical community was lamenting low vaccination rates.
This, curious if I should be able to get a spring one with asthma and diabetes
.
Is there any reason not to get the spring shot?
Are you saying that if one got the shot last fall the overall protection it provided has not yet declined?
Can you say more about what a 49% VE means? E.g. did X% get Covid without the shot and .49X with it, and if so, what is X?
Any data on vaccine effectiveness against long Covid?
You said that “ I’m not convinced that most people over 65 need a spring vaccine.” If you want to educate people and have them take your advice, show the data to support this opinion so people can make an informed judgement.
Thanks for your feedback! I peppered the reasons throughout this post, but I could have summarized them better. Writing Cliff notes in real time is... challenging. There are a few reasons I think this: 1. The vast majority of people in the hospital and dying aren't getting *one* shot a year. Only 5% in the hospital had their fall vaccine, and among those, the majority are those with multiple comorbidities and severely immunocompromised. 2. no observation data presented showed two shots a year are more beneficial than one shot a year. If we recommend an intervention to the Americans, we must have strong evidence. There has been one study (not presented at ACIP) that shows there is very little benefit, actually. 3. There is little evidence of waning thus far from the fall vaccines. 4. Given what we know about immune system memory, multiple comorbidities and age are the biggest problem.
Does this analysis include long COVID?
“Age and comorbities”! Right - over 30 million Americans are over age 65 and an awful lot of us have one or more “comorbidites”. Not having a “Should” rather than a “May” means working very hard to find an MD who will do it - not to mention drug chains! Get real and rediscover your empathy. You’ve spent too much time with the “responsible” public health care bureaucrats.
But are hospitalizations all we care about. Two of my first degree relatives had over 6 months of heart and lung issues post covid. I'm still masking and trying to avoid it, but just because someone isn't hospitalized doesn't mean there aren't serious health complications that will cost us in so many ways. I'm ready to cry because no one seems to care about at risk individuals anymore.
Thanks for the update. If a previous infection should count like a vaccine, it seems obvious that one of the major reasons people aren’t getting vaccinated is because they recently had Covid. This reason doesn’t show up in the CDC survey results, perhaps because of how the survey was designed. Many people I know got Covid in late summer/early fall, even before back-to-school.
What this means is we need to get updated boosters out sooner - not September/October.
So appreciate all you share
I think a big reason the numbers are down for getting vaccinated is that it became commercialized and it cost many. I can give you many examples here in Maine where if the vaccine continues to be free folks would have gotten it
What are your thoughts
They presented some data on this. Let me find it really quick, but I was susprised how much cost wasn't a factor for the *general population*. It is driving inequities though
Dr. Jetelina,
Thank you. From a public health perspective, can you explain why the ACIP is not recommending the spring vaccine for those who have comorbidities / are immunocompromised, even if they have not reached the age of 65? And what is the evidence that supports drawing the line at 65 instead of, say, 55 or 60?
Probably because Medicare kicks in at 65 and those under age 65 may have to pay OOP unless their insurance company covers it. Wouldn’t surprise me if there was a lot of insurance company influence in setting the age to keep costs down. Welcome to American healthcare politics.
Just a reminder on why ACIP might have had to issue a pro forma "should" - because of its statutory role relative to the Affordable Care Act. The only way to guarantee that ACA plans cover vaccines without cost sharing is an affirmative recommendation from ACIP. If you want a compelling reason for ACIP to use "should" versus "may" - there you have it.
Thank you as always for your ACIP Cliff notes, I always look forward to reading your newsletter. I've been run COVID19 vaccine clinics in the metro Boston area since vaccines rolled out in 2021. The biggest difference (we found) between the current 2023-2024 COVID19 immunization season and prior years is the privatization of vaccines and overall cost. While the recommendations mean insurance companies "have to" reimburse for the vaccine, not all insurance companies cover the cost (HMO's out of network won't). The out of pocket cost for the COVID19 vaccine is $170-$190. For those under insured or without insurance, finding a pharmacy that participates in the Bridge Program is challenging. I wish our gov't would cover the full cost of vaccines, this would be so helpful for so many. Thank you again!! p.s. I agree stronger language "should" might be more impactful this spring.
Thanks - as always your posts are so informative.
I’ll add my bit regarding “may” versus “should”. The real life consequences of the wording for who should get the adult RSV vaccine resulted in some medical groups requiring (read delaying) vaccinating people in the target group. This affected family members and friends of mine. So I’m all for “should” in the over 65 group.
My husband and I (79 and 78) have had every COVID vaccine dose offered including last fall just before leaving for a tour of Slovenia/Croatia in October. We both got COVID for the first time with symptoms starting two days apart. It was like a very bad cold (him) or flu (me). Both had fevers for 2-3 days. We are traveling to the UK this June. Soliciting opinions on getting another dose in maybe April? Both of us had lingering fatigue and I think it may be persisting for me.
With the persistent fatigue I would ask your doctor to check a) a full iron panel and b) a full thyroid panel that includes free T3. Both low iron and low FT3 can cause fatigue type symptoms.
Thanks; all WNL
While looking at the impact on hospitalizations is important, it ignores the big issue of long covid. It's been shown that vaccines reduce the risk of long covid. Given the safety of these vaccines for the vast majority, an updated shot every 6 months for the vast majority (including those under 65) would go a long way to prevent more long-covid cases and disability as covid continues to evolve. It would also reduce missed school and work days as it reduces the risk of transmission and severity of illness among those not hospitalized. Hospitalization is not the only important outcome to consider, right?
I have asthma and even colds mess me up for a while. They don't send me to the hospital but they are disruptive. Anything that reduces the amount of time I spend coughing would be great, so I would happily get a shot every 6 months if they let me (and my kids too, as I especially want to reduce their risk of long-covid).
No, I think deaths are also of some importance 😁
From the Boston Globe:
"Americans over the age of 65 should receive a second dose of the booster shot recommended in September, a Centers for Disease Control and Prevention advisory panel voted Wednesday, noting that the extra protection has likely already begun to wane."