Category: health care

CDC ACIP Meeting on Covid 19 Vaccine Additional Dose

The CDC ACIP meeting on February 28, 2024 on the proposal of a Spring booster of the Covid 19 vaccine was interesting and confusing. Initially right after the morning presentations, we were a little confused about whether the committee was targeting only those who got the vaccine booster last fall or everybody. That didn’t make much sense given the concern about low overall uptake of the vaccine.

The presenters also mentioned that getting the Spring Covid booster would be part of a shared clinical decision-making discussion with your doctor, similar to that recommended for the RSV vaccine. That was bewildering because we think that’s part of the reason some people might skip the RSV vaccine, given the news reports last year pointing out you had to have a prescription from a medical provider in some states to get it.

I was pretty interested in learning more about T-cell immunity given the concern about waning which of immunity from vaccines over a few months, which I think was based on neutralizing antibodies from B cells. I thought the CDC web site link to an article about the T-cell immune response suggested that cell mediated immune responses might mean that our immunity might not be waning that quickly. However, one of the presentations, “Evidence to Recommendation” showed a slide indicating that your T-cell immunity gets weaker with age (ref. de Candia P, Prattichizzo F, Garavelli S, Matarese G. T Cells: Warriors of SARS-CoV-2 Infection. Trends Immunol. 2021 Jan;42(1):18-30. doi: 10.1016/j.it.2020.11.002. Epub 2020 Nov 13. PMID: 33277181; PMCID: PMC7664351.)

I’ve read other articles, one of them on the CDC website, which says you may have more durable immunity provided by T-cells, but if I read it carefully, the authors hedge and say that T-cell adaptive immunity may not be as strong when you’re older. (Moss, P. The T cell immune response against SARS-CoV-2. Nat Immunol 23, 186–193 (2022). https://doi.org/10.1038/s41590-021-01122-w).

Later in the afternoon, the committee voted that those who are 65 years old and older should get the spring dose. There was no further discussion of limiting it to only those who got the Covid vaccine in the fall of 2023. There was also no discussion of the shared clinical decision-making detail. The committee upvoted the resolution with a majority.

And yet, the voting question did say: ACIP recommends that persons greater than or equal to 65 years of age “should” (which was changed from “may”) receive an additional dose of 2023-2024 Formula COVID-19 vaccine. The “additional dose” means in addition to the vaccine (monovalent XBB.1.5) given last fall. That’s a relatively select group, when you take the subset of those who are 65 and older.

However, the slides in the “Evidence to Recommendation” had recommended there should be shared clinical decision-making, meaning that you should discuss getting the vaccine with your doctor. However, according to the STAT NEWS article summary of this meeting, substituting the word “should” for “may” would make the conversation with a doctor unnecessary.

Finally, there was no discussion at all of changing the 5-day isolation precaution for those testing positive for Covid-19. If the committee were planning to drop that, as many news agencies recently reported, I would think they’d have discussed it at length at the meeting.

The CDC Director will have to sign off on the additional Covid-19 shot before it’s official.

2/29/2024 Update: CDC Director endorsed the additional dose yesterday.

Thoughts on Upcoming CDC ACIP Meeting

Sena and I are talking about the upcoming CDC meeting on February 28th-29th next week. The agenda looks like they’ll be talking about an “additional dose” of the Covid-19 vaccine.

Given the extent of vaccine fatigue going on, I tried to find a layperson-friendly article on the web about vaccine immunity with details about how long it lasts.

There’s review article from 2022 that helps a little bit. The author says that boosting every few months may not be practical as a long-term strategy. It leads to vaccine fatigue in the population. We all know how low the Covid-19 vaccine uptake has been. The author says that boosters should be offered annually or even less often. There is more to immunity than neutralizing antibodies.

The suggestion of some experts is to offer Covid-19 boosters to whoever wants it. I feel like I’m getting mixed and circular messages when I read that my immunity is “waning,” and I need another one. We’ve gotten every Covid-19 shot since the vaccine campaign began. Experts even differ on whether to call Covid-19 a “seasonal” respiratory virus. That would suggest you could get one shot annually during the respiratory virus season-like the flu shot. Obviously, it’s not that simple if the CDC recommends another Covid-19 vaccine this spring.

And the CDC respiratory virus channel snapshot from February 16, 2024 is a little concerning. A couple of days ago there was a news report that schools in Forest City, Iowa would have to move to remote learning because of outbreaks of influenza, strep throat, and even stomach flu. According to the CDC, respiratory virus activity levels are high all over Iowa, which surprised me this late in the season.

CDC ACIP Meeting February 28-29, 2024 to Discuss Covid-19 and Other Vaccines

There are news stories about a pending CDC-ACIP meeting (February 28-29, 2024) which might include information about a CDC recommendation to possibly add a 3rd additional Covid-19 vaccine booster this spring.

The Covid-19 vaccine portion of the meeting is scheduled for February 28, 2024 at 8:30 AM EST. There will be a vote at 1:55 PM EST that day.

Interestingly, also on the agenda is a discussion about the RSV vaccine on February 29, 2024 at 8:30 AM EST. We wonder whether the committee will talk about the current requirement for a shared clinical-decision making discussion with a physician for getting the RSV vaccine.

New Large Covid-19 Vaccine Study Shows Association with Rare Side Effects Which Other Smaller Studies Have Found

I’ve seen a couple of news stories about the CDC supported large study across many countries which essentially shows that Covid-19 vaccines can be associated with rare side effects. The stories might tend to raise anxiety about the vaccines’ overall safety, which has been repeatedly proven in other studies.

The study is published in the journal Vaccine and the conclusions are consistent with smaller studies showing the Covid-19 vaccines safety although they do have rare side effects.

One of the news stories contacted an expert, Dr. Marc Siegel, clinical professor of medicine at NYU Langone Medical Center, who confirmed that.

Unfortunately, there are over 1200 comments (and counting) containing alarmist and misleading information about the vaccines.

CDC May Change the 5 Day Covid-19 Isolation Guidelines

I see many news headlines reporting that the CDC may be planning to drop the 5 day Covid-19 isolation guidelines. For now I’m taking that as a rumor until the CDC website says something official about it.

Word on the street is that we may know more in April.

Bootless II: Dr. Russell Ledet’s Story

Recall that I had been checking to see if the Distinguished Education Lecture given by Dr. Russell Ledet, MD, PhD on January 17, 2024 during the MLK Celebration of Human Rights would be available for the general public. While somebody may be working on that, I managed to find Dr. Ledet’s YouTube, entitled “Bootless II.” I think it’s a great distillation of his major theme.

Trips and Trip-Killers

I just read this JAMA Network article on trip-killers. It’s about using drugs to stop bad trips caused by hallucinogens.

One mentioned was ketamine. When I was working as a consultation psychiatrist, I was called occasionally to evaluate patients in recovery rooms who were delirious from the ketamine that was sometimes used by anesthesiologists.

I found a paper with a list of ketamine’s limitations, which I think is helpful.

Trips and trip-killers can cause problems.

Thoughts on the Distinguished Education Lecture by Dr. Russell Ledet MD PhD

We enjoyed the Dr. Martin Luther King, Jr. Distinguished Education (originally given on January 17, 2023) by Dr. Russell Ledet. He’s definitely a mover and a shaker and this is another recorded presentation that I wish was available for the general public.

His bio is knockdown impressive. And even more interesting to me is that he’s presently in residency toward boarding in adult psychiatry and child psychiatry as well as pediatrics.

That’s right—triple boarding.

His talk was a fascinating oral autobiography from his upbringing in poverty to his military career, to his undergraduate and graduate college career, and his achievement in organizing a very successful nonprofit, The 15 White Coats. This helps get underrepresented minority students into medicine by giving them inspiration and financial support.

His life story by itself is inspiring. It’s also exhausting. The person introducing him wondered aloud if he ever slept!

He began with a well-known quote by Dr. Martin Luther King, Jr:

“It’s all right to tell a man to lift himself by his own bootstraps, but it is a cruel jest to say to a bootless man that he ought to lift himself by his own bootstraps.”

Dr. Ledet’s story of his path from bootlessness to crowning success is compelling. You really have to hear it from him to get a clear idea of how difficult it was. It’s hard to imagine that a star like him once rummaged through dumpsters for food for the family while his mother was on the lookout to make sure he didn’t get caught.

I think a big part of what kept him going was his wife and kids. In fact, his wife, Mallory Alise, insisted that he take the path because of her fear he would die if he continued a dangerous assignment in the military.

A member of the audience who had a career similar to Dr. Ledet asked a question about what more should he do to make sure young people of color would get the kind of opportunities to succeed. Dr. Ledet had a very good answer, but that was not the most interesting part of the interaction. Firstly, the questioner didn’t sound (I know this is going to sound crass) black. He sounded more like someone who had grown up in the Northern United States—like me. But during the course of the conversation, it was clear that he was black. He just didn’t sound like Dr. Ledet. He also mentioned, almost in passing, that some people of color who succeed may develop imposter syndrome.

This sounded strange at first, but I quickly realized that I sometimes had felt like an imposter. This cuts two ways with me. One was the obvious context in which I came out of an impoverished background to finish college and medical school, and had a career as a consultation-liaison psychiatrist at a university medical center where I published and taught for many years. At times I felt like a phony.

The other situation in which imposter syndrome arose was when I went to Huston-Tillotson University (an HBCU formerly called Huston-Tillotson College) in Austin, Texas back in the 1970s. Most of the students were from the region. I had a Northerner’s accent and somebody once remarked on it, asking me “Why do you talk so hard?” I was easily identified simply because of how I spoke. I didn’t always feel comfortable, despite for the first time being not the only black guy in school. Ironically, I didn’t feel like I fit in, even in an HBCU. Even among those who looked like me, I sometimes felt like a phony. But that was not an enduring affliction.

And I think Dr. Ledet has a great deal of confidence and energy. More power to him.

FDA Issues Warning Not to Use Tianeptine

There have been several warnings from the FDA and others for several years (going back to at least 2014) against using tianeptine. It’s used as an antidepressant in other countries, but “FDA is warning consumers not to purchase or use any Neptune’s Fix products, or any other product with tianeptine — a potentially dangerous substance that is not FDA-approved for any medical use but is illegally sold with claims to improve brain function and treat anxiety, depression, pain, opioid use disorder and other conditions.”

Tianeptine has been called other names including Neptune’s Fix, Zaza, Coaxil, Stablon, Tianna Red, and others.

It reportedly has been banned in several states. Southern Iowa Mental Health Center published an educational web page in 2022 indicating that a review between 2000 and 2017 found a sharp untick in tianeptine-related poisoning calls during that time period.

The web page also pointed out that “The study specifically noted that while the drug was implicated in just five poisoning calls back in 2014, that figure rose to 38 in 2015, 83 by 2016, and 81 by 2017. And most of those calls involved relatively young people, between the ages of 21 and 40.”