Yesterday morning after much reading and discussion with colleagues and with considerable consternation the skeptical cardiologist received a second booster.
I reviewed my angst-ridden decision-making on the 4th jab in a previous post. Briefly, I am >65 years of age without other risk factors for severe COVID-19 (I have asthma and hypertension but don’t consider these risk enhancers). I received an initial set of Pfizer shots in January of 2021 as soon as they were authorized and I jumped the gun on getting a Pfizer booster in August of 2021. I have upcoming inpatient hospital duties beginning April 18.
Two days ago, the FDA and CDC authorized the Pfizer and Moderna vaccines for a second booster in adults >50 years of age.
The data from an Israeli study showing a marked reduction in hospitalizations and death during their intense Omicron COVID-19 surge with a second booster were convincing.
Deaths due to Covid-19 in the second-booster group were 22% of the first-booster group.
Mixing and Matching Vaccines
In the time I had before my 9 AM appointment at CVS to receive Moderna’s Spikevax as my second booster I tried to decide if I should be getting Moderna’s booster or Pfizer’s booster. Choosing all Pfizer would classify as homologous boosting, going with Moderna would be heterologous. The FDA says either approach is fine.
The FDA EUA authorizes a single (0.25 mL) booster dose of the Moderna COVID-19 Vaccine at least 5 months after completing a primary series of the Moderna COVID-19 Vaccine or SPIKEVAX.
The regular full dose of Moderna is 100 micrograms of nucleoside-modified messenger RNA (mRNA) compared to Pfizer’s full dose vaccine which is 30 micrograms. The Moderna booster dose is 1/2 of the full dose so you still get more mRNA (50 micrograms) than with Pfizer’s full dose booster.
Three pieces of information convinced me to switch to Moderna. If I had previously gotten all Moderna I would have switched to Pfizer:
- A study published in JAMA in January using data prior to Omicron showed those receiving two Moderna shots had lower hospitalizations than those receiving two Pfizer.
- This article published in Cell showed that in macaques exposed to Omicron the Moderna vaccine (mRNA-1273) and an Omicron specific mRNA vaccine elicited comparable immunity and protection shortly after the boost.
- Finally, a study published on Tuesday showed differing cellular and humoral immune responses to the Pfizer and Moderna vaccines which suggested to me that switching between the two types makes sense to provide a broader immune response. Moderna provided increased levels of several antibodies compared to Pfizer:
differences emerged across epitope-specific responses, with higher concentrations of receptor binding domain (RBD)- and N-terminal domain-specific IgA observed in recipients of mRNA-1273 (Moderna). Antibodies eliciting neutrophil phagocytosis and natural killer cell activation were also increased in mRNA-1273 (Moderna) vaccine recipients as compared to BNT162b2 recipients. Antibodies eliciting neutrophil phagocytosis and natural killer cell activation were also increased in mRNA-1273 vaccine recipients as compared to BNT162b2 recipients
The Booster Experience
Scheduling (and rescheduling) this vaccination was easily done online with CVS. Whether I indicated I was immunocompromised or not the system let me schedule the appointment for the booster. I was never asked if this was a first or second booster.
One of the commenters on my previous post indicated CVS turned him away saying he was ineligible. Others have indicated that Rite-Aid did not deny them jab #4.
When I entered the CVS at 850 AM yesterday I checked in using a link I was texted. I was first in line and was asked my birthdate and for a copy of my vaccine card. I showed a digital image of my card with the first two injections. At no time was I asked if I was immunocompromised or if I had had a first booster.
The pharmacist near the front desk told me that I was lucky because this was the first dose from a brand new bottle. I said “excellent.”
After waiting about 15 minutes a lady came out and directed me to a chair and asked if a left arm injection was OK. I said yes and took off my outer shirt, leaving a long-sleeve T-shirt. She rattled off some instructions which included staying hydrated. I rolled up the sleeve and she told me that it might be more painful because the rolled up sleeve was affecting the injection site. I said “should I take off my T-shirt?” She said it wasn’t necessary. I said “I’d rather take it off and have less pain” and took off my T-shirt.
The injection (left deltoid) was fairly painless. Before she bustled back into the pharmacy I asked her why this particular pharmacy (which happened to be extremely close to my house) was administering Moderna. She told me that CVS sends Pfizer to some pharmacies and Moderna to others. They don’t send both in order “to reduce errors.”
Booster Side Effects
I had had little to no side effects from the first 3 Pfizer injections. Four hours after the first one I began feeling extremely tired. I took a nap for 45 minutes and felt totally normal thereafter. With the others all I felt was minor soreness at the injection site.
It is now 24 hours since the Moderna jab. The left deltoid is moderately tender to touch and with certain shoulder motions I feel moderate pain, nothing that I would take an analgesic for.
Around the 4 hour mark afterwards I felt antsy with a slight tightness. After eating those symptoms resolved. At the 6 hour mark I went on a bike ride. I felt a little more winded than usual and my heart rate was higher but this was likely due to running out of nebivolol, a beta-blocker that slows the heart rate and lowers the blood pressure.
This morning I feel back to normal.
While I was searching Twitter prior to the injection, I came across a comment that said the booster would cost $800. This statement is manifestly inaccurate.
The federal government has mandated that you don’t have to pay anything for COVID-19 vaccinations. The CDC website states very clearly “Vaccines were paid for with taxpayer dollars and will be given free of charge to all people living in the United States, regardless of insurance or immigration status.”
CVS asks for insurance information when you register online for a vaccine but it is not necessary to give them this information.
Individual Risks Calculations and Other FactorsInfluencing the Decision
The decision to get this second booster was not easy. Although I’m over age 68 years my overall risk of getting seriously ill or dying from COVID-19 is very low given my vaccinated status.
You can plug your age and other factors in the 3 risk calculators at the British Heart Foundation to see where you stand.
You can also assess the risk of various COVID exposures at this Harvard site.
The fourth booster is definitely not needed for those under age 50 years with no other risk factors. For those over age 80 years or those who are immunocompromised it is highly recommended.
For the rest of us this becomes a highly individualized decision. As I indicated I would not have gotten it if I was not looking at potential high exposure situations. I would not have gotten it if I had had significant side effects from prior COVID vaccinations. One reader commented on experiencing frequent symptomatic PVCs after his third injection. That would have steered me away from a fourth.
Another reader wrote “My husband (67) and I (almost 69) got the initial 2 Moderna shots in Feb and March 2021. Got the booster precisely 6 months later. We have some health issues, so we continue to mask, lead a quiet life, etc. However, we will be traveling overseas in October. Should we get the 2nd booster now? Or wait until a little closer to our trip—perhaps August or September?”
Timing is important as studies clearly show waning of immunity over time. If you do decide to get it, it makes sense to get it about 2-3 weeks before a trip or an event at which you anticipate significant exposure
Prior COVID-19 infections: “natural immunity”
As one reader pointed out, if you have had a documented COVID-19, the calculus changes:
I have had double Pfizer’s, then was positive (probably for delta), and then got a booster because it was required for work. I would say that if you had one or more previous infections plus 1 booster, the benefit of a fourth jab would be infinitesimal. another strategy would be to wait until you got an infection and then take Paxlovid to give you that 90% protection from death and hospitalization
My concern about his proposed strategy (which I have also considered) is that I have concern for the availability of paxlovid and question whether just being >65 would qualify for its use.
Whether you decide to get the second booster or not, I hope you base your decision on good information.
N.B. After posting this I note that MedPage Today has just published a good post with discussion on mixing and matching vaccine doses from various experts.