"To be, or not to be" is the opening phrase of a soliloquy by Hamlet as he contemplates death and suicide. Hamlet is mad at his mom; she married his uncle who killed his father. And so, one of the themes is whether to take action (revenge) or not to take action. It is an emotional and psychological conundrum. Hamlet finds himself going crazy as he is unable to make a decision and then stick with it. Some of the more impulsive characters in the play, like Hamlet's uncle, find tragedies coming their way due to their excessive willingness just to act.

So how do we decide on this current question to boost or not to boost?

It should not be an emotional decision; it should not be based on fear or politics or the urging of the biotechs that manufacture the booster. It has to be based on science, so currently, we need to pause and examine the science. This is how we decided that hydroxychloroquine was not effective and that it is okay to use aspirin and ibuprofen if you get COVID. It's how we discovered that dexamethasone is very helpful to avoid respiratory failure for those with worsening COVID. And science has shown us that the vaccines are effective and safe. This recent publication is the world's largest study to date on the safety of vaccines.

The good news is that despite the COVID vaccine breakthrough infections, and the expected decline in the level of antibodies, the further we get from the time the vaccine was given, we are still seeing the vaccine as very effective in preventing hospitalizations, respiratory failure and death. The more people who are vaccinated, the better. Even those who recently have contracted the illness should get a least one vaccination. 

And the further encouraging news is that in the last couple of days, the prevalence in Maryland has slightly dropped and is now plateaued at under 5%. This is an excellent sign. It means that herd immunity is increasing and people are making good decisions about staying away from indoor crowds, wearing face-masks, continuing to wash their hands, and those who have respiratory symptoms are self-isolating and getting tested.

So, what do we know presently?

• The Israeli data has shown that the third vaccine for over 60-year-olds offered five to six times greater protection after 10 days with regard to serious illness and hospitalization.

• Most Israelis over the age of 60 who were vaccinated and got sick had co-morbidities such as diabetes and obesity.

• No matter what the vaccine effectiveness is in preventing COVID illness, the important question for boosters is whether they lower the risk of severe disease or death. We do not have randomized, controlled studies that show this as of today.

• With a third booster, we need to consider the risk of worse vaccine side effects and toxicity. Randomized trials and close observation are needed to exclude worse safety signals like inflammation of the heart (myocarditis and pericarditis) which presently is a very small risk but was more common after the second mRNA dose. Will they be more common after a third dose?

• Finally, consider this: "I think we've scared people," said Dr. Paul Offit, Director of the Vaccine Education Center at Children's Hospital of Philadelphia and an advisor to NIH and the FDA. "We sent a terrible message. We just sent a message out there that people who consider themselves fully vaccinated were not fully vaccinated. And that's the wrong message because you are protected against serious illness."

So based on the above, here is my take regarding to boost, or not to boost, which is subject to change based on the science as it rolls in.

• If you are immuno-suppressed, take the booster.

• If you are over 75 years old, take the booster.

• If you are over 60 and have one or more co-morbidities such as diabetes, heart disease, lung disease or obesity, take the booster.

As a reminder, I'm no longer sending out daily updates and instead, I'm updating you periodically. I continue to enjoy writing these updates. Initially, these were only sent to my patients, however, I've been humbled to learn that, through social media, these writings have been forwarded and re-forwarded to many. This has brought me great joy to know that this simple act of sharing facts, thoughts, opinions, and hopes have touched you in some way. Hopefully I've been able to reassure you, maybe make you smile and laugh, soothe your worries, and comfort you. And maybe, just maybe, I've helped you to be in the moment!

Reach out. Stay connected. Stay home. Save lives. The power of one. Be well.

Feel free to forward this on: spread the word, not the virus.

HAO

24/7

Harry Oken, M.D.

Adjunct Professor of Medicine

University of Maryland, School of Medicine

Office 410-910-7500

Fax   410-910-2310 

Cell   443-324-0823