You end with "you know what to do": but with the lack of guidance from CDC and local health departments, it's easy to question basic mitigation practices. My county went CDC red a week ago--and absolutely no one is aware. It hasn't changed any behavior--including no masks in an optometrist office. So even though masking when indoors, ventilate, get your boosters, stay home when sick seems wise--and I read the CDC red county guidelines-they go further--when the public narrative is "it's over" and masks are for outliers/extremists, it's so easy to question basic mitigation behavior.
I'm a physician, with some immune dysfunction, and I found myself checking in with my doctor for reassurance.
So, please spell out "you know what to do"--increasingly, we don't.
Increase ventilation & room air changes per hour. Retro-fit buildings if possible; if not, add properly-sized HEPA filters or build Corsi-Rosenthal boxes. (Schools don’t have to be Petri dishes for viral illness if ventilation is adequate.)
(Maintain all filters properly and clean or change them regularly.)
Use CO2 meters (personal or room-mounted) to measure air quality and stay aware of safe CO2 levels. Mask up or leave when in the red zone.
Always wear well-fitting N95 masks in public places especially if you are at risk or immunocomprised; when cases are ^ or High and when in large groups; or anywhere you can’t know others’ status and want to avoid getting sick. Especially when traveling on public transportation. Think of masking this way: You masked are protecting others; others masked are protecting you.
Test, test, test: Test “in” to groups gathering. Test “out” of same when you get home. If you are positive, you are infectious.
You really *do* want to get infections under control because this virus is evolving to evade immunity and render at least some therapeutics useless.
There is talk of Long Covid becoming a huge “Disability Event” in the coming months and years. This is not good for humanity and the economy.
And urge your representatives in Congress to put money into developing nasal vaccines, providing sick pay, providing masks and tests, and investing in public health, for God’s sake. It’s what functioning societies do: care for their citizens.
Your approach is unfortunately not being supported by national or local public health: the department of health advisory I received yesterday about the Red level stated that while the CDC recommends masking, it does NOT require it.
Increasingly, NPI mitigation is ceasing and being labeled as negative.
The "your mask protects me, my mask protects you" scheme doesn't really work any more if others aren't masking. That's why I wear N95's when I'm out in public - a fresh one every day. I was able to get a whole bunch online from Wal-Mart, and my flex spend reimbursed me for all 150 of them.
How are you getting a second bivalent when it’s not approved yet (for anyone including immunocompromised)- the committee meets at the end of January to decide next steps....?
A family member sent me this and I am really confused by how they talk about the data. The state that the studies show that more vaccinations increases your risk of contracting COVID-19. This is contrary to all other research I have seen. Can you help me understand how the authors are coming to this conclusion? My family member now regrets getting boosted even though I have been advocating for months that they get the booster.
Thank you for the update. The issue has come up as to whether those who received a bivalent booster in September should get another booster for increased protection during the winter. There is no guidance on this that I am aware of. I don’t know if there is enough data available to make an informed decision. Any thoughts?
I wonder the same. Any guidance on this appreciated.
Several of the immunologists, infex disease folks, etc that I follow also are talking about waning booster immunity. Would like some direction on this since we’re early adopters.
Thank you for this v helpful newsletter. Twitter & SubStack have outperformed the agencies who are supposed to protect us throughout this seemingly endless pandemic - through our tax dollars no less. Can’t thank you all enough.
What does "this" refer to in the sentence, "For really the first time, reported case numbers have completely decoupled from wastewater, so we can’t rely on this anymore. Wastewater is clearly on the rise." I thought that earlier posts explained that we cannot rely on case numbers because of unreported home tests. The quoted sentence seems to be saying that we cannot rely on wastewater, either, but I doubt that is your message. (It's often hazardous to use "this" as a pronoun!)
I quite agree, Mr. Schoenbach. “This” likely is referring to Total case numbers and not wastewater data but I certainly could be wrong. I am aware that there are new websites were self testing can be reported, but I do not know if that is state by state or it’s a federal website. Clearly, the denominator is murky. 
Thanks for your updates. As a long hauler I am curious about repeat infections and the use of Paxlovid. Does Paxlovid lose its effectiveness if someone uses multiple times? Also, does Paxlovid dampen the antibody uptick with getting COVID so you are more susceptible to a new infection (from a different variant)? Reinfecting monthly from school is happening here so knowing more about how Paxlovid works when it’s used frequently would be very helpful to know about. Thanks.
"People vaccinated with the fall booster have an 18.6 times lower risk of dying from COVID-19 than unvaccinated people right now. The risk of infection is also three times lower." --- Does this apply to the XBB's? The graph only seems to go to sometime in November.
A friend of mine sent me this link to an article he saw in the Wall Street Journal that referred to a journal article in Nature, in December: The WSJ article examined some studies that suggest that vaccines might be fueling new covid variants. I was wondering what you think of this? You did a blog on original sin a while back. I assume that this article is related.
Dr John Campbell, who has been a steady voice throughout the pandemic, as well as pro-vax until recently, has raised similar concerns. He’s a retired nurse teacher based in England. He recently made a plea to the British government and public health authorities to stop all vaccines until a comprehensive risk/benefit study can be conducted. In addition to the concerns you raise, he’s also concerned about unexplained excess mortality. His most recent videos are posted on Rumble because YouTube would label them “misinformation” and remove them at once.
New flash: science does not work on the basis of argument by personal authority. Nor does it depend on how well someone presents themselves on a video. It uses facts. Argument from authority is how religion works.
In the video I saw (I haven’t seen all of them), Dr Campbell was very respectful, and his questions about efficacy, safety and public health seemed like things many of us have been wondering about lately. And if science can’t have a conversation without one side immediately silencing the other side with labels such as “misinformation” and “dark side” - or worse, outright censorship - those in charge of steering our country through the pandemic will be deprived of understanding the true picture - which will only harm all of us and make things much worse than they need to be. Truth requires free speech and for all sides to willingly and respectfully participate in the dialogue.
so true, and I have experienced some of that with some of my YLE discussions about a novel treatment utilizing a repurposed drug. I had hoped to generate some questions and some lively interchange, but as my colleague and I have noted, no one wants to address any aspect or fear of being labeled as “woke“ or in our case, “Off-the-wall“ or worse, “purveyors of voodoo medicine“. 2000 recipients of an off label/re-purposed drug that is FDA approved and declared safe for one condition doesn’t automatically make it unsafe for another human disorder. It needs a carefully designed trial to sort it out and open minds for prescribing, especially true in the face of a disease like COVID-19 that continues to kill people despite EUA protocols (MCAbs) incorporating an infusion or drug that may be useful for one variant, but not for subsequent variants. Treating advanced and severely ill COVID-19 patients with a repurposed drug that uniformly squashes the symptoms, puts the victims back on their feet and back on the job within days is not something to be ignored.
If you’re referring to the liver medication that works on the ACE receptor (sorry that’s all I understood about it, I’m very much not a doctor!), I’ve definitely followed that up by asking my father to discuss it with his cardiologist, who has been up to date on all the latest for the last three years. I know she’ll be very open to anything that will protect her medically vulnerable patients, and will read the study. I just don’t comment very much online because as a non-medical person, I don’t have much to offer to help the comment community, but I’m reading every comment on every post here.
I’m just now remembering you might be talking about the UNC study, so adding a PS here. After seeing your comments, I followed up and read an article about that study (this is the palliative care setting one, yes?) and I was confused about what conclusions I should draw, other than that the medication used there definitely did seem to deserve further study. I wish I were in a position to know how further studies get approved and funded.
I watched most of the video you posted. I’m not at all impressed with Dr Wilson. Dr Campbell has more recent videos clarifying his position on Ivermectin, and he’s very careful to adhere to NIH, FDA and YouTube content policy.
Again, I haven’t watched everything from Dr Campbell, but his overall demeanor and thoroughness is more consistent with someone seeking the truth (vs Dr Wilson whose main method for debunking is “I’m right, they’re wrong” without offering anything more substantive).
The best way to discredit someone today is to hurl an Ivermectin bomb at them, and to that end, Dr Wilson is quick to launch his cheap shot.
Anecdotally, I'm in healthcare in a surgical sub-specialty where covid tests are required a few days before surgery. We've been seeing a lot of positive tests and calling people who are shocked and annoyed their surgery is being cancelled as they are asymptomatic. I wonder if this is why wastewater and cases have drifted apart?
Interesting anecdote - In primary care I am seeing a lot of people with this pattern:
1) Head cold symptoms for a few days
2) Things get worse, headache and body aches, fever and cough
3) Hmmmm. Maybe I should test for Covid?
4) Covid test positive, and then a call to our office
5) Narrow or missed window to start easy antiviral Paxlovid
I've had to arrange remdesivir infusions at our hospital center for some high risk people beyond the Paxlovid window or with contraindications. Doing another one today for my very, very high risk patient sent home from the ER with no antiviral plan at all b/c "she's on Eliquis" (a contraindication for Paxlovid but not remdesivir).
*Always test for Covid with "head colds" and "winter(?) allergies." The test are covered by insurance, and about $10 each anyway. Early diagnosis is good for you, your contacts, your community, and the world!
Here's an anecdote that synthesizes Dr. Jetelina's post... I have a patient whose young daughter is hospitalized right now with Influenza, RSV, Covid, and pneumonia - all at once.
and then there are all the many people I know who, with those symptoms, do a home test for Covid, and it's negative. But then, maybe on Day 6 or later, they finally test positive -- but it's too late for Paxlovid. I guess the answer is to get a PCR test whenever you have cold symptoms, but I don't know what the insurance situation is now for those tests, and most people are "just not into it" anymore.
Good point - we still send a limited number of PCR swabs out from our office - but mostly these are sent from our urgent care locations, as we only have limited physical capacity in the office to safely separate and evaluate ill patients...
I’ve noticed this too with my friends and family. Unfortunately all the PCR testing centers near me are closing. Do you think nowadays it’s taking more days before people test positive on home tests, and if so, why? Does this only happen with vaccinated people? Or is it the new variants?
I"ve read that it has to do with milder cases due to vaccination. There just isn't enough virus in the nose to register a positive on a home test. This seems like a good thing -- except I'm also reading that, for some people, you can have just a bit of virus in the nose, but more has already gone into other areas of the body. The tragedy here is inadequate funding for the development of the nasal vaccines, which would block the virus where it enters the body!
The delay for PCR results has been several days where I live. Given that people may wait for a couple of days before deciding to have a PCR test (or getting one approved), I suspect that many patients are missing the "window" for Paxlovid treatment.
Does anyone know if there are any clinical trials where the window is being adjusted?
Noticing an upswing in hospitals and urgent cares not even testing for classic COVID symptoms as well. Then when the patient returns several days later (feeling worse) and is finally tested (and positive), they are told they are out of the antiviral treatment window. Seeing this trend even with immuno patients and high risk. Not sure why.
I heard an interesting segment on NPR this morning regarding the pandemic and effects on gut bacteria. This would be an interesting topic to hear more about in the future or even a recap of what we know about gut bacteria in regards to epidemiology.
I agree. A gut doctor/scientist claims she was the first to discover COVID in feces. This led to sewage being tested. Does anybody know who else is claimng credit for being the first to discover COVID in feces?
I believe there was a non-peer reviewed article abstract in biomed arxiv back in 2020 that suggested the Chinese had done some wastewater surveillance of high tise buildings. But my memory is very poor 😢
Thanks for the update. Not surprising, unless one subscribes to conspiracy narratives or social media-driven pseudoscience (especially, these days, on Twitter). Sadly, we have a fourth pandemic that has continued unabated since 2020: politically driven misinformation.
Of interest is Figure 2, which shows the more doses, the more likely you are to have caught Covid 19 in the population studied. This is the image making rounds on social media.
The study looks at vaccine and infection for roughly 50,000 employees at any of the Cleveland Clinic locations in Ohio (previously I thought they included Dubai and Florida).
While the study isn't peer reviewed yet, I'm not sure that matters all that much as it is a straightforward analysis which can easily be replicated. It also comes from the #2 hospital in the world.
Two things that stand out to me from the data which are of interest:
1) There were ~6000 unvaccinated employees they tracked, which I find odd as the Clinic had mandated it as terms of employment. I'm unclear how 12% managed to remain unvaccinated. I've asked friends employed at the Clinic and this was their understanding too (though they are physicians and weren't entirely certain if they fully enforced for lower level positions due to resource shortages).
2) Only 20% of employees chose to get the Bivalent vaccine. The #2 Hospital in the world, and still they only managed to get 20% uptake.
In the results they mention:
"This is not the only study to find a possible association with more prior vaccine doses and higher risk of COVID-19. A large study found that those who had an Omicron variant infection after previously receiving three doses of vaccine had a higher risk of reinfection than those who had an Omicron variant infection after previously receiving two doses of vaccine [21]. Another study found that receipt of two or three doses of a mRNA vaccine following prior COVID-19 was associated with a higher risk of reinfection than receipt of a single dose [7]"
So this isn't a one-off.
I'm currently reading "The Invisible Siege" by Dan Werb which tells the amazing story of how the mRNA vaccines came to save the day from the Covid pandemic (it is a very well written book, but also comes off like a press release for Moderna or a retcon of Ralph Baric), yet it has passages like this (p97):
______________________
“Baric was one of the few scientists who saw the stakes clearly. It wasn’t that an eventual SARS vaccine might work or not. It was that a vaccine could be either an antidote or a poison for a future pandemic-ready coronavirus, and there might be no way to tell them apart until it was too late.
Baric knew that vaccines that didn’t accurately match their targets could weaken human resistance and inadvertently make people who were inoculated sicker."
______________________
And I wonder, what to make of the fact that 2 years out we have possible evidence that this very scenario Baric feared of SARS vaccines is playing out. Is this Antibody-dependent enhancement? Original Antigenic Sin? What are possible explanations why highly vaccinated populations are seeing *more* of the thing they vaccinated against?
There is a huge difference between vaccine efficacy determined with a randomized, controlled group and the observed effectiveness in a retrospective study. I think one should be very careful not to over-interpret observations from uncontrolled studies such as this. Individual activities, behaviors, exposure (in-and outside the clinic), current health, and personal decisions about vaccination can easily confound such studies. In addition, there was no serology performed to determine actual prior infection status. The authors rightly emphasize these, and other, variables that might confound the observations. Unfortunately, social media are an abysmal tool for informing the public about such research, and will inevitably be commandeered by cherry-picking advocates with a particular axe to grind, or money to make.
To answer your specific questions about antibody-dependent enhancement or "original antigenic sin", I don't think this work was sufficient to study such questions: I suspect that this would require a large and expensive controlled study. Moreover, since the greatest potential benefit of vaccination is for the aged and vulnerable, such a study might pose significant ethical challenges (e.g. deliberately witholding a potentially life-saving therapy).
Which is why there is a low uptake of that vaccine, in my opinion. We are well passed emergency guess and checking. We should only be injecting well tested compounds. I’d like to see a replication of the Cleveland Clinic study. As I am on the cusp of “elderly,” the study is less relevant for me. But, I am interested for my thirty-something children. Also, I found it interesting that my own doctor did not recommend another booster for me. I am thrice-jabbed and once infected (omicron). She is after me to get my pneumonia vaccine which I will get. I did get my flu shot.
The first COVID vaccine trials were "easy"—they involved a homogeneous pool of subjects who had no prior exposure to the virus, and there were very few variants—so that it was possible to get a clear measure of efficacy. In contrast, we now have an extremely complex mix of people with different times of exposure to different viruses and or different vaccines at different times, so it would be very hard to sort out cause and effect. In addition, the virus is mutating rapidly, so the chances are that different subjects would be exposed to different viruses during the course of a study.
There is also the challenge of deciding what endpoint to use to measure effectiveness, because symptoms could be dependent on previous exposures.
I don't claim to be an expert, but I think that "secondary" and in vitro surrogate endpoints will probably be the best route—measuring the levels of antibodies induced after vaccination, and measuring whether the antibodies are able to block infectivity using in vitro models. Admittedly, these endpoints would probably be better at estimating the ability of the vaccine to inhibit infection, rather than acute disease severity or long-COVID.
Encouragingly, In a recent study of high-risk, elderly patients, the bivalent vaccine was highly effective (>70%) in preventing hospitalizations due to new COVID infection.
For me, the use of boosters (especially for the most at-risk) is analogous to wearing a seatbelt—a legally-required procedure that can be uncomfortable sometimes, but saves thousands of lives each year.
You wrote: "In addition, there was no serology performed to determine actual prior infection status." But don't those serology tests become far less accurate over time as anti-bodies fade from the body? At least a year ago I found out a COVID serology test I could get for myself could not detect anti-bodies after a period of months. Thus, a test done now might not tell me if I was infected and produced antibodies in 2020.
I'm wondering if Antibody-dependent enhancement or Original Antigenic Sin at play. Wish Katelyn would explore why the most vaccinated countries in the world continue to see wave after wave.
I see what you were talking about, the diagram that showed “The risk of COVID-19 also varied by the number of COVID-19 vaccine doses previously received. The higher the number of vaccines previously received, the higher the risk of contracting COVID-19 (Figure 2).” However, assuming this was a sound study the analysis showed benefit (although not as much as hoped for) from the bivalent booster under the defined circumstances,
“This study found that the current bivalent vaccines were about 30% effective overall in protecting against infection with SARS-CoV-2, when the Omicron BA.4/BA.5 lineages were the predominant circulating strains. The magnitude of protection afforded by bivalent vaccination was similar to that estimated in a recent study using data from the Increasing Community Access to Testing (ICATT) national SARS-CoV-2 testing program [16].”
Oof, this is confusing, at least to a non-scientist like me. All I know is that I got my first case of COVID a couple of weeks after getting my booster, but was thinking that was because I was traveling in a stressful situation and not taking the precautions that I should.
SD: it seems to me that one’s antibody response to any antigenic stimulus i.e. booster in this case, is a Somewhat unique biologic event for every person – age dependent and medical issues, etc. Some might have adequate immune capacity for neutralizing antibodies after two weeks and others might take 3–4 weeks. Also, if you we’re traveling and under stress, fatigue, etc. you are at higher risk for acquiring the infection, I should think. Crowded terminals, conveyances, restaurants, etc. then there is the absence of a mask at certain points i.e. in the restroom or other venues, that pose added risk when the environmental airflow is not adequate.  The only way you can feel comfortable is to take your booster, stay home and hope for the best, but always, always wear your mask and be sure it’s new, fits well and it isn’t all crumpled up and dirty, etc.  I am still an advocate for boosters, and in my own mind, a 5-6 month hiatus is as long as most people should go in the winter months when people are naturally more confined and congregate indoors. Perhaps 6-8 months would be reasonable in warmer climates with much less indoor exposures. A shout out to everyone who has contributed to this YLE Forum. I am very impressed with the questions and responses as well as the references provided. Thank you all!  thank you, Dr. Jelena, for allowing such diverse comments. Some viewpoints seem a little bit above and beyond but so far as I can tell, no one has been denied their say. 
Your experience is very common. I found Georgia state data in a chart that runs contrary to other data. For those who got boosters, the 0-15 day period is the lowest bar for breakthrough infections. Then the bars get very high, with the highest bars for the periods right after the 0-15 day bar. This is the time when the boosters are supposed to be providing the best protection.
Huge thank you on this comprehensive summary of what is 'current'.
I've noticed that here in the PNW (Pacific NorthWest), many folks who appear to be older than 50 or 60, are near 90% masked (observed during the Seattle Symphony Orchestra Christmas event, as well as at the local supermarket).
Well, these two over 70 year olds fully vaccinated (bivalent last October), finally caught COVID. We don't know where we caught it. We took our daughter, and family, out for dinner on Dec 21, and ate outside. We are pretty good about limiting ourselves to doing outdoor activities, but admit to recently not being as firm about wearing our masks indoors. Our daughter had a cold, as had her kids (all tested negative, twice), so of course our first thought was we picked up her cold (hubby got symptoms first). His first mild symptoms showed on Christmas Eve. Some sniffles, a very slight cough. We hosted the family on Christmas Eve, but had our front door open the whole time. Then the family came over for Christmas morning. Same scenario. On Monday morning I had him test just to rule it out. He was positive. Informed the whole family and everyone tested. Still, no one else tested positive, except for me. I tested Tuesday morning (27), because it's the day I visit my 95 year old mother in her facility and I just wanted to be cautious (I had no symptoms). I was positive. The worst symptoms I developed was a mild fever of 100.4 with chills that resolved after about 4 hours. Other than that, we both felt like we had a cold. We both tested last Tuesday, both still positive with waning symptoms (and a thinner, fainter positive line). We are both past our quarantine time, so when we have to go inside we wear our KN95 masks. We'll test again Friday because there is no need to before then. We aren't going anywhere, so no point. We both feel just fine, and we never took Paxlovid. Neither of us have underlying conditions, but if we had we would have requested it. It's obviously still put there, as is so much else, so I'm back to wearing my mask inside, if only so I don't catch the other nasty stuff out there!
I do wonder, though, when will COVID be considered just something else you can catch, without the quarantine period? I've noticed (since I have four grandchildren in schools and I volunteer for my daughter, who is a teacher), that kids are attending schools again with obvious cold symptoms, just like before. I was an educator myself and I remember the days of coughs and sniffles, and helping kids blow their noses! That's probably why I have such a good immune system. I don't get sick very often.
A neighbor's partner was just diagnosed with Covid. She is vaxxed x2, boostered x2 and had the bivalent shot. I suspect it's XBB 1.5 to cut thru the defenses like that. A little scary considering our shot histories and hers are identical. The pandemic is far from over.
Should older adults get get a new booster 4 months after their last one? This is a question which has no direct answer, but a recent study showed that protection for nursing home residents fell four months after their last vaccine.. ( study led by Oliver Stirrup, University College London, London, UK)
You end with "you know what to do": but with the lack of guidance from CDC and local health departments, it's easy to question basic mitigation practices. My county went CDC red a week ago--and absolutely no one is aware. It hasn't changed any behavior--including no masks in an optometrist office. So even though masking when indoors, ventilate, get your boosters, stay home when sick seems wise--and I read the CDC red county guidelines-they go further--when the public narrative is "it's over" and masks are for outliers/extremists, it's so easy to question basic mitigation behavior.
I'm a physician, with some immune dysfunction, and I found myself checking in with my doctor for reassurance.
So, please spell out "you know what to do"--increasingly, we don't.
Actually, we do:
Get vaxxed & keep up with boosters.
Increase ventilation & room air changes per hour. Retro-fit buildings if possible; if not, add properly-sized HEPA filters or build Corsi-Rosenthal boxes. (Schools don’t have to be Petri dishes for viral illness if ventilation is adequate.)
(Maintain all filters properly and clean or change them regularly.)
Use CO2 meters (personal or room-mounted) to measure air quality and stay aware of safe CO2 levels. Mask up or leave when in the red zone.
Always wear well-fitting N95 masks in public places especially if you are at risk or immunocomprised; when cases are ^ or High and when in large groups; or anywhere you can’t know others’ status and want to avoid getting sick. Especially when traveling on public transportation. Think of masking this way: You masked are protecting others; others masked are protecting you.
Test, test, test: Test “in” to groups gathering. Test “out” of same when you get home. If you are positive, you are infectious.
You really *do* want to get infections under control because this virus is evolving to evade immunity and render at least some therapeutics useless.
There is talk of Long Covid becoming a huge “Disability Event” in the coming months and years. This is not good for humanity and the economy.
And urge your representatives in Congress to put money into developing nasal vaccines, providing sick pay, providing masks and tests, and investing in public health, for God’s sake. It’s what functioning societies do: care for their citizens.
Your approach is unfortunately not being supported by national or local public health: the department of health advisory I received yesterday about the Red level stated that while the CDC recommends masking, it does NOT require it.
Increasingly, NPI mitigation is ceasing and being labeled as negative.
“NPI” - masking - is pretty much all we’ve got to protect ourselves, thanks to the CDC.
The "your mask protects me, my mask protects you" scheme doesn't really work any more if others aren't masking. That's why I wear N95's when I'm out in public - a fresh one every day. I was able to get a whole bunch online from Wal-Mart, and my flex spend reimbursed me for all 150 of them.
I'm getting my 2nd bivalent next week.
How are you getting a second bivalent when it’s not approved yet (for anyone including immunocompromised)- the committee meets at the end of January to decide next steps....?
I would love to know your thoughts on this opinion piece circulating from the Wall Street Journal: https://www.wsj.com/articles/are-vaccines-fueling-new-covid-variants-xbb-northeast-antibodies-mutation-strain-immune-imprinting-11672483618
A family member sent me this and I am really confused by how they talk about the data. The state that the studies show that more vaccinations increases your risk of contracting COVID-19. This is contrary to all other research I have seen. Can you help me understand how the authors are coming to this conclusion? My family member now regrets getting boosted even though I have been advocating for months that they get the booster.
Any help would be greatly appreciated!
There have been several reputable dr’s who have come out against that article saying it is completely false, if that helps?
Thank you for the update. The issue has come up as to whether those who received a bivalent booster in September should get another booster for increased protection during the winter. There is no guidance on this that I am aware of. I don’t know if there is enough data available to make an informed decision. Any thoughts?
I wonder the same. Any guidance on this appreciated.
Several of the immunologists, infex disease folks, etc that I follow also are talking about waning booster immunity. Would like some direction on this since we’re early adopters.
Thank you for this v helpful newsletter. Twitter & SubStack have outperformed the agencies who are supposed to protect us throughout this seemingly endless pandemic - through our tax dollars no less. Can’t thank you all enough.
What does "this" refer to in the sentence, "For really the first time, reported case numbers have completely decoupled from wastewater, so we can’t rely on this anymore. Wastewater is clearly on the rise." I thought that earlier posts explained that we cannot rely on case numbers because of unreported home tests. The quoted sentence seems to be saying that we cannot rely on wastewater, either, but I doubt that is your message. (It's often hazardous to use "this" as a pronoun!)
I quite agree, Mr. Schoenbach. “This” likely is referring to Total case numbers and not wastewater data but I certainly could be wrong. I am aware that there are new websites were self testing can be reported, but I do not know if that is state by state or it’s a federal website. Clearly, the denominator is murky. 
Thanks for your updates. As a long hauler I am curious about repeat infections and the use of Paxlovid. Does Paxlovid lose its effectiveness if someone uses multiple times? Also, does Paxlovid dampen the antibody uptick with getting COVID so you are more susceptible to a new infection (from a different variant)? Reinfecting monthly from school is happening here so knowing more about how Paxlovid works when it’s used frequently would be very helpful to know about. Thanks.
Can you speak to the excess deaths issue. It does not seem to be getting any attention, and it would seem to be very important!
"People vaccinated with the fall booster have an 18.6 times lower risk of dying from COVID-19 than unvaccinated people right now. The risk of infection is also three times lower." --- Does this apply to the XBB's? The graph only seems to go to sometime in November.
A friend of mine sent me this link to an article he saw in the Wall Street Journal that referred to a journal article in Nature, in December: The WSJ article examined some studies that suggest that vaccines might be fueling new covid variants. I was wondering what you think of this? You did a blog on original sin a while back. I assume that this article is related.
https://www.wsj.com/articles/are-vaccines-fueling-new-covid-variants-xbb-northeast-antibodies-mutation-strain-immune-imprinting-11672483618
I think it's what I'd expect from the WSJ. Which is not the most trusted name in science news.
Eric Topol
@EricTopol
No, vaccines DO NOT induce variants. That's what infections do.
Blatant misinformation:
"Growing evidence also suggests that repeated vaccinations may make people more susceptible to XBB"
physician-scientist, author, editor
http://drerictopol.com
Ground Truths: http://erictopol.substack.com
La Jolla, CAscripps.edu/translational
Dr John Campbell, who has been a steady voice throughout the pandemic, as well as pro-vax until recently, has raised similar concerns. He’s a retired nurse teacher based in England. He recently made a plea to the British government and public health authorities to stop all vaccines until a comprehensive risk/benefit study can be conducted. In addition to the concerns you raise, he’s also concerned about unexplained excess mortality. His most recent videos are posted on Rumble because YouTube would label them “misinformation” and remove them at once.
New flash: science does not work on the basis of argument by personal authority. Nor does it depend on how well someone presents themselves on a video. It uses facts. Argument from authority is how religion works.
In the video I saw (I haven’t seen all of them), Dr Campbell was very respectful, and his questions about efficacy, safety and public health seemed like things many of us have been wondering about lately. And if science can’t have a conversation without one side immediately silencing the other side with labels such as “misinformation” and “dark side” - or worse, outright censorship - those in charge of steering our country through the pandemic will be deprived of understanding the true picture - which will only harm all of us and make things much worse than they need to be. Truth requires free speech and for all sides to willingly and respectfully participate in the dialogue.
so true, and I have experienced some of that with some of my YLE discussions about a novel treatment utilizing a repurposed drug. I had hoped to generate some questions and some lively interchange, but as my colleague and I have noted, no one wants to address any aspect or fear of being labeled as “woke“ or in our case, “Off-the-wall“ or worse, “purveyors of voodoo medicine“. 2000 recipients of an off label/re-purposed drug that is FDA approved and declared safe for one condition doesn’t automatically make it unsafe for another human disorder. It needs a carefully designed trial to sort it out and open minds for prescribing, especially true in the face of a disease like COVID-19 that continues to kill people despite EUA protocols (MCAbs) incorporating an infusion or drug that may be useful for one variant, but not for subsequent variants. Treating advanced and severely ill COVID-19 patients with a repurposed drug that uniformly squashes the symptoms, puts the victims back on their feet and back on the job within days is not something to be ignored.
If you’re referring to the liver medication that works on the ACE receptor (sorry that’s all I understood about it, I’m very much not a doctor!), I’ve definitely followed that up by asking my father to discuss it with his cardiologist, who has been up to date on all the latest for the last three years. I know she’ll be very open to anything that will protect her medically vulnerable patients, and will read the study. I just don’t comment very much online because as a non-medical person, I don’t have much to offer to help the comment community, but I’m reading every comment on every post here.
I’m just now remembering you might be talking about the UNC study, so adding a PS here. After seeing your comments, I followed up and read an article about that study (this is the palliative care setting one, yes?) and I was confused about what conclusions I should draw, other than that the medication used there definitely did seem to deserve further study. I wish I were in a position to know how further studies get approved and funded.
I watched most of the video you posted. I’m not at all impressed with Dr Wilson. Dr Campbell has more recent videos clarifying his position on Ivermectin, and he’s very careful to adhere to NIH, FDA and YouTube content policy.
Again, I haven’t watched everything from Dr Campbell, but his overall demeanor and thoroughness is more consistent with someone seeking the truth (vs Dr Wilson whose main method for debunking is “I’m right, they’re wrong” without offering anything more substantive).
The best way to discredit someone today is to hurl an Ivermectin bomb at them, and to that end, Dr Wilson is quick to launch his cheap shot.
Here you go
https://clinicaltrials.gov/ct2/results?cond=COVID-19&term=ivermectin&cntry=&state=&city=&dist=&Search=Search&fund=0&fund=1.
can you expand on this?
Anecdotally, I'm in healthcare in a surgical sub-specialty where covid tests are required a few days before surgery. We've been seeing a lot of positive tests and calling people who are shocked and annoyed their surgery is being cancelled as they are asymptomatic. I wonder if this is why wastewater and cases have drifted apart?
Interesting anecdote - In primary care I am seeing a lot of people with this pattern:
1) Head cold symptoms for a few days
2) Things get worse, headache and body aches, fever and cough
3) Hmmmm. Maybe I should test for Covid?
4) Covid test positive, and then a call to our office
5) Narrow or missed window to start easy antiviral Paxlovid
I've had to arrange remdesivir infusions at our hospital center for some high risk people beyond the Paxlovid window or with contraindications. Doing another one today for my very, very high risk patient sent home from the ER with no antiviral plan at all b/c "she's on Eliquis" (a contraindication for Paxlovid but not remdesivir).
*Always test for Covid with "head colds" and "winter(?) allergies." The test are covered by insurance, and about $10 each anyway. Early diagnosis is good for you, your contacts, your community, and the world!
Here's an anecdote that synthesizes Dr. Jetelina's post... I have a patient whose young daughter is hospitalized right now with Influenza, RSV, Covid, and pneumonia - all at once.
Unvaccinated against flu and Covid.
and then there are all the many people I know who, with those symptoms, do a home test for Covid, and it's negative. But then, maybe on Day 6 or later, they finally test positive -- but it's too late for Paxlovid. I guess the answer is to get a PCR test whenever you have cold symptoms, but I don't know what the insurance situation is now for those tests, and most people are "just not into it" anymore.
Good point - we still send a limited number of PCR swabs out from our office - but mostly these are sent from our urgent care locations, as we only have limited physical capacity in the office to safely separate and evaluate ill patients...
I’ve noticed this too with my friends and family. Unfortunately all the PCR testing centers near me are closing. Do you think nowadays it’s taking more days before people test positive on home tests, and if so, why? Does this only happen with vaccinated people? Or is it the new variants?
I"ve read that it has to do with milder cases due to vaccination. There just isn't enough virus in the nose to register a positive on a home test. This seems like a good thing -- except I'm also reading that, for some people, you can have just a bit of virus in the nose, but more has already gone into other areas of the body. The tragedy here is inadequate funding for the development of the nasal vaccines, which would block the virus where it enters the body!
The delay for PCR results has been several days where I live. Given that people may wait for a couple of days before deciding to have a PCR test (or getting one approved), I suspect that many patients are missing the "window" for Paxlovid treatment.
Does anyone know if there are any clinical trials where the window is being adjusted?
Noticing an upswing in hospitals and urgent cares not even testing for classic COVID symptoms as well. Then when the patient returns several days later (feeling worse) and is finally tested (and positive), they are told they are out of the antiviral treatment window. Seeing this trend even with immuno patients and high risk. Not sure why.
I mean, if I catch it, I'll fib about my symptoms to get Paxlovid. I've had a CMP in the past 12 months so I can get it straight from CVS
I heard an interesting segment on NPR this morning regarding the pandemic and effects on gut bacteria. This would be an interesting topic to hear more about in the future or even a recap of what we know about gut bacteria in regards to epidemiology.
I agree. A gut doctor/scientist claims she was the first to discover COVID in feces. This led to sewage being tested. Does anybody know who else is claimng credit for being the first to discover COVID in feces?
I believe there was a non-peer reviewed article abstract in biomed arxiv back in 2020 that suggested the Chinese had done some wastewater surveillance of high tise buildings. But my memory is very poor 😢
Thanks for the update. Not surprising, unless one subscribes to conspiracy narratives or social media-driven pseudoscience (especially, these days, on Twitter). Sadly, we have a fourth pandemic that has continued unabated since 2020: politically driven misinformation.
Can you comment on the study (preprint) out of the. Cleveland Clinic that found that each booster received increases the risk of an infection.
For those interested, here is the study Bridget references:
"Effectiveness of the Coronavirus Disease 2019 (COVID-19) Bivalent Vaccine"
https://www.medrxiv.org/content/10.1101/2022.12.17.22283625v1.full
Of interest is Figure 2, which shows the more doses, the more likely you are to have caught Covid 19 in the population studied. This is the image making rounds on social media.
The study looks at vaccine and infection for roughly 50,000 employees at any of the Cleveland Clinic locations in Ohio (previously I thought they included Dubai and Florida).
While the study isn't peer reviewed yet, I'm not sure that matters all that much as it is a straightforward analysis which can easily be replicated. It also comes from the #2 hospital in the world.
Two things that stand out to me from the data which are of interest:
1) There were ~6000 unvaccinated employees they tracked, which I find odd as the Clinic had mandated it as terms of employment. I'm unclear how 12% managed to remain unvaccinated. I've asked friends employed at the Clinic and this was their understanding too (though they are physicians and weren't entirely certain if they fully enforced for lower level positions due to resource shortages).
2) Only 20% of employees chose to get the Bivalent vaccine. The #2 Hospital in the world, and still they only managed to get 20% uptake.
In the results they mention:
"This is not the only study to find a possible association with more prior vaccine doses and higher risk of COVID-19. A large study found that those who had an Omicron variant infection after previously receiving three doses of vaccine had a higher risk of reinfection than those who had an Omicron variant infection after previously receiving two doses of vaccine [21]. Another study found that receipt of two or three doses of a mRNA vaccine following prior COVID-19 was associated with a higher risk of reinfection than receipt of a single dose [7]"
So this isn't a one-off.
I'm currently reading "The Invisible Siege" by Dan Werb which tells the amazing story of how the mRNA vaccines came to save the day from the Covid pandemic (it is a very well written book, but also comes off like a press release for Moderna or a retcon of Ralph Baric), yet it has passages like this (p97):
______________________
“Baric was one of the few scientists who saw the stakes clearly. It wasn’t that an eventual SARS vaccine might work or not. It was that a vaccine could be either an antidote or a poison for a future pandemic-ready coronavirus, and there might be no way to tell them apart until it was too late.
Baric knew that vaccines that didn’t accurately match their targets could weaken human resistance and inadvertently make people who were inoculated sicker."
______________________
And I wonder, what to make of the fact that 2 years out we have possible evidence that this very scenario Baric feared of SARS vaccines is playing out. Is this Antibody-dependent enhancement? Original Antigenic Sin? What are possible explanations why highly vaccinated populations are seeing *more* of the thing they vaccinated against?
There is a huge difference between vaccine efficacy determined with a randomized, controlled group and the observed effectiveness in a retrospective study. I think one should be very careful not to over-interpret observations from uncontrolled studies such as this. Individual activities, behaviors, exposure (in-and outside the clinic), current health, and personal decisions about vaccination can easily confound such studies. In addition, there was no serology performed to determine actual prior infection status. The authors rightly emphasize these, and other, variables that might confound the observations. Unfortunately, social media are an abysmal tool for informing the public about such research, and will inevitably be commandeered by cherry-picking advocates with a particular axe to grind, or money to make.
To answer your specific questions about antibody-dependent enhancement or "original antigenic sin", I don't think this work was sufficient to study such questions: I suspect that this would require a large and expensive controlled study. Moreover, since the greatest potential benefit of vaccination is for the aged and vulnerable, such a study might pose significant ethical challenges (e.g. deliberately witholding a potentially life-saving therapy).
Agree, but there are very few randomized controlled trials for Bivalent vaccine so we have to make do with what we get.
Which is why there is a low uptake of that vaccine, in my opinion. We are well passed emergency guess and checking. We should only be injecting well tested compounds. I’d like to see a replication of the Cleveland Clinic study. As I am on the cusp of “elderly,” the study is less relevant for me. But, I am interested for my thirty-something children. Also, I found it interesting that my own doctor did not recommend another booster for me. I am thrice-jabbed and once infected (omicron). She is after me to get my pneumonia vaccine which I will get. I did get my flu shot.
The first COVID vaccine trials were "easy"—they involved a homogeneous pool of subjects who had no prior exposure to the virus, and there were very few variants—so that it was possible to get a clear measure of efficacy. In contrast, we now have an extremely complex mix of people with different times of exposure to different viruses and or different vaccines at different times, so it would be very hard to sort out cause and effect. In addition, the virus is mutating rapidly, so the chances are that different subjects would be exposed to different viruses during the course of a study.
There is also the challenge of deciding what endpoint to use to measure effectiveness, because symptoms could be dependent on previous exposures.
I don't claim to be an expert, but I think that "secondary" and in vitro surrogate endpoints will probably be the best route—measuring the levels of antibodies induced after vaccination, and measuring whether the antibodies are able to block infectivity using in vitro models. Admittedly, these endpoints would probably be better at estimating the ability of the vaccine to inhibit infection, rather than acute disease severity or long-COVID.
Encouragingly, In a recent study of high-risk, elderly patients, the bivalent vaccine was highly effective (>70%) in preventing hospitalizations due to new COVID infection.
https://www.cdc.gov/mmwr/volumes/71/wr/mm715152e2.htm
For me, the use of boosters (especially for the most at-risk) is analogous to wearing a seatbelt—a legally-required procedure that can be uncomfortable sometimes, but saves thousands of lives each year.
You wrote: "In addition, there was no serology performed to determine actual prior infection status." But don't those serology tests become far less accurate over time as anti-bodies fade from the body? At least a year ago I found out a COVID serology test I could get for myself could not detect anti-bodies after a period of months. Thus, a test done now might not tell me if I was infected and produced antibodies in 2020.
Yes, I read this yesterday and would like to know as well.
I'm wondering if Antibody-dependent enhancement or Original Antigenic Sin at play. Wish Katelyn would explore why the most vaccinated countries in the world continue to see wave after wave.
Additional recent findings that may be relevant: https://www.science.org/doi/10.1126/sciimmunol.ade2798
I looked at the pre print briefly and I don’t believe it showed that.
What do the results indicate? Should the information be taken into consideration by all? By some?
I see what you were talking about, the diagram that showed “The risk of COVID-19 also varied by the number of COVID-19 vaccine doses previously received. The higher the number of vaccines previously received, the higher the risk of contracting COVID-19 (Figure 2).” However, assuming this was a sound study the analysis showed benefit (although not as much as hoped for) from the bivalent booster under the defined circumstances,
“This study found that the current bivalent vaccines were about 30% effective overall in protecting against infection with SARS-CoV-2, when the Omicron BA.4/BA.5 lineages were the predominant circulating strains. The magnitude of protection afforded by bivalent vaccination was similar to that estimated in a recent study using data from the Increasing Community Access to Testing (ICATT) national SARS-CoV-2 testing program [16].”
Oof, this is confusing, at least to a non-scientist like me. All I know is that I got my first case of COVID a couple of weeks after getting my booster, but was thinking that was because I was traveling in a stressful situation and not taking the precautions that I should.
SD: it seems to me that one’s antibody response to any antigenic stimulus i.e. booster in this case, is a Somewhat unique biologic event for every person – age dependent and medical issues, etc. Some might have adequate immune capacity for neutralizing antibodies after two weeks and others might take 3–4 weeks. Also, if you we’re traveling and under stress, fatigue, etc. you are at higher risk for acquiring the infection, I should think. Crowded terminals, conveyances, restaurants, etc. then there is the absence of a mask at certain points i.e. in the restroom or other venues, that pose added risk when the environmental airflow is not adequate.  The only way you can feel comfortable is to take your booster, stay home and hope for the best, but always, always wear your mask and be sure it’s new, fits well and it isn’t all crumpled up and dirty, etc.  I am still an advocate for boosters, and in my own mind, a 5-6 month hiatus is as long as most people should go in the winter months when people are naturally more confined and congregate indoors. Perhaps 6-8 months would be reasonable in warmer climates with much less indoor exposures. A shout out to everyone who has contributed to this YLE Forum. I am very impressed with the questions and responses as well as the references provided. Thank you all!  thank you, Dr. Jelena, for allowing such diverse comments. Some viewpoints seem a little bit above and beyond but so far as I can tell, no one has been denied their say. 
Your experience is very common. I found Georgia state data in a chart that runs contrary to other data. For those who got boosters, the 0-15 day period is the lowest bar for breakthrough infections. Then the bars get very high, with the highest bars for the periods right after the 0-15 day bar. This is the time when the boosters are supposed to be providing the best protection.
Huge thank you on this comprehensive summary of what is 'current'.
I've noticed that here in the PNW (Pacific NorthWest), many folks who appear to be older than 50 or 60, are near 90% masked (observed during the Seattle Symphony Orchestra Christmas event, as well as at the local supermarket).
"Forewarned is forearmed. "
Heinz
My grandfather's name was Heinz! I don't believe I've met any others besides the ketchup brand lol. So nice to see. Were you named after anyone?
Heinz is a very common name in Germany; sort of like 'John' is here.
Well, these two over 70 year olds fully vaccinated (bivalent last October), finally caught COVID. We don't know where we caught it. We took our daughter, and family, out for dinner on Dec 21, and ate outside. We are pretty good about limiting ourselves to doing outdoor activities, but admit to recently not being as firm about wearing our masks indoors. Our daughter had a cold, as had her kids (all tested negative, twice), so of course our first thought was we picked up her cold (hubby got symptoms first). His first mild symptoms showed on Christmas Eve. Some sniffles, a very slight cough. We hosted the family on Christmas Eve, but had our front door open the whole time. Then the family came over for Christmas morning. Same scenario. On Monday morning I had him test just to rule it out. He was positive. Informed the whole family and everyone tested. Still, no one else tested positive, except for me. I tested Tuesday morning (27), because it's the day I visit my 95 year old mother in her facility and I just wanted to be cautious (I had no symptoms). I was positive. The worst symptoms I developed was a mild fever of 100.4 with chills that resolved after about 4 hours. Other than that, we both felt like we had a cold. We both tested last Tuesday, both still positive with waning symptoms (and a thinner, fainter positive line). We are both past our quarantine time, so when we have to go inside we wear our KN95 masks. We'll test again Friday because there is no need to before then. We aren't going anywhere, so no point. We both feel just fine, and we never took Paxlovid. Neither of us have underlying conditions, but if we had we would have requested it. It's obviously still put there, as is so much else, so I'm back to wearing my mask inside, if only so I don't catch the other nasty stuff out there!
I do wonder, though, when will COVID be considered just something else you can catch, without the quarantine period? I've noticed (since I have four grandchildren in schools and I volunteer for my daughter, who is a teacher), that kids are attending schools again with obvious cold symptoms, just like before. I was an educator myself and I remember the days of coughs and sniffles, and helping kids blow their noses! That's probably why I have such a good immune system. I don't get sick very often.
We are both now negative. Tested this morning! Whew!
A neighbor's partner was just diagnosed with Covid. She is vaxxed x2, boostered x2 and had the bivalent shot. I suspect it's XBB 1.5 to cut thru the defenses like that. A little scary considering our shot histories and hers are identical. The pandemic is far from over.
Should older adults get get a new booster 4 months after their last one? This is a question which has no direct answer, but a recent study showed that protection for nursing home residents fell four months after their last vaccine.. ( study led by Oliver Stirrup, University College London, London, UK)