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COVID-19 Q&A: Where are we now?

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As COVID-19 infection rates surge in several states across the U.S., many people have questions about how to best protect themselves and their loved ones from the virus.

With the holidays approaching, Jodie Guest, PhD, professor and vice chair of the department of epidemiology at Rollins School of Public Health, and Carlos del Rio, MD, distinguished professor of medicine, epidemiology and global health and executive associate dean of Emory University School of Medicine at Grady Health System, teamed up to answer questions about the latest developments related to COVID-19 vaccines, treatments and holiday safety measures.

Their conversation is part of an online video series hosted by Guest, who also leads the Emory COVID-19 Outbreak Response Team, answering questions related to the COVID-19 pandemic. Watch the full conversation between Guest and del Rio here.

Q: What is the latest news on COVID-19 vaccines for children?

A: Pfizer’s COVID-19 vaccines are now available for children as young as age 5. On Nov. 2, the Centers for Disease Control and Prevention (CDC) endorsed the recommendation of its advisory committee to expand eligibility for Pfizer’s vaccine to children ages 5 through 11, after previously recommending the vaccine for children ages 12 and older last spring.

In the U.S., more than 1.9 million children ages 5-11 have been infected with COVID-19; of those children, 8,300 have been hospitalized and 94 have died, making COVID-19 the eighth-leading cause of death for children in this age group, Guest says. Vaccinating children significantly reduces their risk of severe illness or death due to COVID-19.

“We vaccinate for diseases that have far fewer deaths and hospitalizations than COVID-19, such as hepatitis A,” Guest notes. “Prior to the vaccines for hepatitis A, there were on average three pediatric deaths a year, and we compare that to COVID-19 with an annual average of 66 deaths in this age group before vaccines.”

Vaccination also reduces the risk of children transmitting the virus to other members of their households and communities.

Q:  What is the difference between vaccination and natural immunity?

A: Natural immunity to COVID-19 is “something that we still need to understand,” del Rio says, noting that older people and those who have been hospitalized with severe illness from COVID-19 are more likely to have a robust immune response from natural infection. Data suggests this natural immune protection lasts around six months.

“When someone in their 60s who had COVID and was in the hospital says to me, ‘Do I need to get vaccinated?’ I say, ‘You can wait six months.’ You’re probably better off waiting than getting vaccinated right away. For children, it’s a little different, because a lot of those kids were probably asymptomatic or minimally symptomatic with their infection. It’s very unlikely they have the level of robust immunity that you need, that the vaccine is capable of producing,” del Rio says.

Both experts recommend vaccination against COVID-19 regardless of age or potential natural immunity. “With the amount of COVID in our communities, you will encounter COVID,” del Rio says. “When COVID finds you, you’re better off when you’re vaccinated than if you’re unvaccinated.”

Q: Who needs a COVID-19 booster shot?

A: The CDC recommends booster shots for people who are ages 65 and older, people who reside in long-term care settings, and people ages 50 through 64 who have underlying medical conditions such as diabetes, hypertension or HIV disease. For those who received a primary vaccination series (two doses) of Pfizer or Moderna vaccines, boosters should be administered at least six months after the second dose.

The CDC also recommends booster shots for any individual who received the Johnson & Johnson vaccine. Boosters for these individuals should be administered two months after the first shot. 

Adults younger than 50 who have underlying medical conditions are also eligible to receive booster shots, along with people who may be at high risk of exposure to COVID-19 such as health care workers, grocery workers and teachers.

Some people may not need boosters to remain well-protected from COVID-19. “While there’s waning efficacy over time, the efficacy of these vaccines in preventing severe disease, hospitalization and death — even if you don’t get boosted — continues to be extremely good,” del Rio emphasizes.

Q: Which vaccine is the best booster?

A: The CDC has approved “mixing and matching” COVID-19 vaccines, meaning that any of the three COVID-19 vaccines currently available in the U.S. can be safely administered as a booster dose. del Rio notes that he and colleagues at Emory participated in a clinical study which found that all combinations of the three vaccines are safe and generate immune responses.

“The most important thing about the mix and match study is that you don’t need to go out there finding the vaccine you got” for your primary series, he says. “You can get boosted with whatever is available.”

For members of high-risk populations, del Rio says any type of COVID-19 booster shot is better than none; however, he recommends Pfizer or Moderna boosters for those who were initially vaccinated with Johnson & Johnson.

Q: What drugs are available for the treatment of COVID-19?

A: There are several treatments available that can reduce the risk of hospitalization and death due to COVID-19. Monoclonal antibodies can effectively prevent the progression of COVID-19 illness if administered early on after infection, but since they must be injected intravenously at special clinics, and because patients may be charged treatment fees, del Rio says that “they’re not a great opportunity for everybody.”

There are new drugs on the horizon that could make COVID-19 treatment more accessible, including an oral antiviral pill called molnupiravir. Initially discovered and developed by Emory researchers, molnupiravir is already authorized for COVID-19 treatment in the U.K. and is currently under consideration for emergency use authorization in the U.S. by the Food and Drug Administration.

In clinical trials, molnupiravir reduced the risk of hospitalization and death due to COVID-19 by as much as 50%. Along with an antiviral pill being tested by Pfizer, del Rio says the potential availability of oral treatments will be “a game-changer.”

While these therapeutics are promising, Guest and del Rio maintain that the best way to reduce hospitalizations and deaths due to COVID-19 is to get vaccinated. “We always say an ounce of prevention is worth a pound of cure,” del Rio emphasizes.

Q: How important is it to continue testing for COVID-19 infection?

A: As COVID-19 continues to spread at a fast rate, diagnostic testing remains a critical tool for identifying positive cases and preventing transmission. However, testing availability has not always been consistent.

“Access to testing is something that we need to continue working on,” del Rio says. Guest also describes seeing the demand for tests decrease over the course of the pandemic.

“I don’t think that there’s a lot of urgency to consider getting tested anymore, the way there was a year and a half ago,” she says. “Every time we had a testing event, we would have lines that would start hours before we began testing. Now, we can be at a testing event for four hours and maybe see 25 to 50 people come by to get tested.”

Although at-home rapid tests can be expensive at drug stores (around $25 for a box of two tests), del Rio recommends keeping some on hand if possible. “If you start having the sniffles, don’t feel good, have a sore throat or have a cough, you can rapid-test yourself right away,” he says. Testing at the first sign of symptoms is important because treatments such as monoclonal antibodies and molnupiravir must be administered early in the disease’s course.

Q: How should people prepare for holiday gatherings this year?

A: As the holidays approach, del Rio stresses the continued importance of COVID-19 mitigation strategies to prevent transmission.

“We’re still diagnosing 75,000 people a day. We still have over 40,000 people hospitalized. We’re still having over 1,200 people die every day in our country,” he says. “So, the numbers are coming down, but they’re not down where I would like to see to feel totally safe.”

Guests at holiday gatherings should be fully vaccinated against COVID-19 if age-eligible and should consider getting tested for COVID-19 between 24 and 72 hours in advance. Celebrations should also take place outdoors or with open windows when possible.

“And you’ve got to tell everybody, if anybody has symptoms or doesn’t feel good: don’t come,” del Rio adds.

Q: Have we reached an endemic level of COVID-19?

A: “At some point in time, we were aiming for COVID eradication. That’s not going to happen, so we need to understand what endemicity is going to look like,” del Rio says.

“In my mind, having less than 10 cases per 100,000 in the population, having a positivity rate in testing under 5%, having less than 5 cases per 100,000 in the hospital, and having less than 100 deaths per day at the country level would be probably a place where I would feel very comfortable,” he says, adding that countries such as Iceland and Denmark have already reached these levels of endemicity.

“With 1,200 deaths a day, we’re still way too high, and so much higher than a comfortable level of learning to live with COVID-19,” Guest responds.

del Rio compares the current state of the pandemic to the seventh inning of a baseball game. “We haven’t won the game, and it’s not the time to say, ‘We’re done; we can now bring our second team in because this is our game.’ No — we actually have to bring in our best closer, get our best batters, because in order to win the game you’ve got to go until the last inning, at the last out,” he says. “We’re all tired, we all want this to be over. But the reality is, it’s not over.”

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