How doctors can talk about COVID-19 bivalent boosters with patients

The original COVID-19 vaccines and boosters have done a great job preventing severe illness and hospitalization. But then came Omicron and its subvariants, which were more transmissible than the other strains of SARS-CoV-2. And because the Omicron BA.5 subvariant evaded infection and vaccine-provoked immunity, breakthrough infections and reinfections have become more common as the virus evolves.

That is why COVID-19 vaccine boosters needed an update for improved protection. Yet with the bivalent COVID-19 booster available in time for the holidays, patients aren’t lining up to get their bivalent booster.

A Kaiser Family Foundation survey found that awareness of the bivalent COVID-19 boosters is lacking. The survey found that 31% of adults have only heard “a little” and 20% “nothing at all” about the bivalent boosters. Meanwhile, about one-third have already gotten a new booster or intend to get one as soon as they can. Among adults 65 or older, 45% say they have gotten the bivalent booster or intend to get it as soon as possible.

On top of that, only 19% of parents of children 6 months through 4 years old say their child has gotten vaccinated against COVID-19. This is up from 7% in July, but 53% of parents of children in this age range say they will not get their child vaccinated. Vaccine uptake among children 5–11 years old and teenagers ages 12–17 has also slowed in recent months. This data comes as children 5 or older are now eligible for the COVID-19 bivalent booster.

In a recent discussion, Sandra A. Fryhofer, MD, chair of the AMA Board of Trustees and liaison to the Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices, took time to share how physicians can incorporate COVID-19 bivalent boosters into their conversations with patients to increase uptake.

“The main thing is just keep encouraging the bivalent booster,” said Dr. Fryhofer. “I found that if you don’t mention it, a lot of patients don’t ask because they don’t realize this booster is different than the others.”

“It’s not our previous booster. This is a new one. It’s new and improved and hopefully this will really help us get through the winter and see the end of COVID-19,” she said.

“I don't think people realize how different this is than the boosters that they've already received and why it's important to get it now,” said Dr. Fryhofer, noting that “bivalent means it contains two types of things. This particular vaccine is half original strain, or the ancestral strain, which is contained in all the previous boosters.

“And then half of it is also directed specifically to target the BA.4 and BA.5 subvariants that are currently circulating,” she added. “Patients may say, well, it really has three things in it. No, it’s because even though BA.4 and BA.5 have different mutations, it turns out their spike protein is the same and that’s what is used to make the vaccine.”

“When the bivalent booster was originally approved, it was for those 12 and older. But these bivalent boosters are now authorized for children as young as 5,” said Dr. Fryhofer, noting that the updated COVID-19 bivalent booster for Pfizer-BioNTech is authorized for those 5 or older while Moderna is available for kids 6 and up.

“There’s now another COVID-19 vaccine using a more traditional technology platform available. A two-dose primary series of Novavax protein subunit COVID-19 vaccine is now authorized for those ages 12 and older,” she said, noting that “on October 19, 2022, the FDA also authorized Novavax as a monovalent booster for those 18 and older who either are unable or unwilling to get the updated mRNA bivalent booster.”

However, “you have to wait longer to get the Novavax booster. A Novavax monovalent booster cannot be administered until at least six months after the last COVID-19 primary series vaccine dose and is only available to those who have not previously received a COVID-19 booster,” Dr. Fryhofer explained. “But even if you choose Novavax for your primary series, you can still get an mRNA booster. Mixing and matching is allowed.”

“There’s also concern that previous infection may not protect against future infections,” said Dr. Fryhofer, noting that while the timing after getting last COVID vaccine dose is at least two months for mRNA bivalent boosters, patients should wait “at least three months from COVID-19 infection” before receiving either the bivalent mRNA booster or the monovalent Novavax booster.

“So, if you do have an infection, you build up some immunity. That infection-induced immunity as well as vaccine-induced immunity wanes with time,” she explained, echoing that “the CDC recommendations are two months from your last vaccine dose for mRNA booster, six months after last primary series vaccine dose for Novavax booster, and at  least three months from COVID infection.”

“The monovalent mRNA boosters are now a thing of the past—they're not allowed anymore,” said Dr. Fryhofer, noting “the only kind of mRNA booster that’s now currently authorized by the FDA is the bivalent Omicron BA.4-BA.5 specific booster.”

“Since the Novavax booster is monovalent, its coverage does not specifically target Omicron BA.4 and BA.5,” she explained. That means “the bivalent booster is now the only mRNA booster in town. The monovalent mRNA booster is history.”

“And if you had a monovalent mRNA booster—I’ll call it the old-fashioned booster—two months later you should recommend patients go ahead and get this bivalent mRNA booster to get the most updated protection available,” Dr. Fryhofer said.

“Another argument to use with patients is, people are not wearing their masks anymore and already in the southern hemisphere we’re seeing a harder, more severe flu season and that could happen here,” said Dr. Fryhofer. The combination of COVID-19 and flu “that we’ve been concerned about for the last couple years, it never came to fruition, but it could happen this year.

“This could be the year and now that we are sort of seeing the light at the end of the tunnel and people are taking their masks off and doing more in-person things, that to me is an even bigger reason to go ahead and get boosted so you can stay protected,” she added.

“Even though many people have been vaccinated and boosted and have some protection, we’re certainly in a better place than we were when the pandemic started,” Dr. Fryhofer said. “There are those around us for whom their immune system doesn’t work as well.

“So, getting those boosters and the vaccines they’re not going to build up the protection that other people will,” she added, noting that patients should get the bivalent booster “not only to protect themselves, but to protect those around you too.”

“It’s the same sort of thoughts that we think about when we administer flu vaccines—we worry most about the patients who are older, patients who have chronic medical conditions, women who are pregnant and also the very young,” Dr. Fryhofer said. “Those are the same groups that we worry about most as having severe complications with COVID.”

“We’re seeing the number of people who are infected go down. We’re seeing the number of deaths go down. But we’re not totally out of the pandemic yet,” said Dr. Fryhofer. And with people not wearing masks, “we really need to use this opportunity to take advantage of vaccines that really help us get through this COVID and  flu season and get through this next couple of months so we can get back to enjoying life.”

The CDC says it is OK to get the bivalent mRNA booster or the monovalent Novavax booster and flu vaccine at the same time if patients are eligible and the recommended timing coincides.

“It’s now time to go for the gusto, double up and get protected so you can get on with your life and enjoy the holidays,” she said. “You want to be with your family, so this is just another step to help protect you so you can spend time and have a safer family gathering—happy Thanksgiving, happy vaccinating.”

While it is important for physicians to share their story of getting the bivalent booster, “it’s important to be transparent and honest and understand that you might be one of the people who does have some of those side effects—we’ve all come to know and dread—that’s associated with getting the COVID vaccine,” said Dr. Fryhofer.

“But these symptoms only last about a day and then you’re protected, and you’ll live to see the next day,” she said. “So, one day of things not being perfect is well worth the price—to me—of the protection.”