Editor’s note: Find the latest long COVID news and guidance in Medscape’s Long COVID Resource Center.
Jackie Dishner hasn’t been the same since June 2020, when COVID-19 robbed her of her energy level, ability to think clearly, and sense of taste and smell. Yet at 58, the Arizona writer is in no hurry to get the latest vaccine booster. “I just don’t want to risk getting any sicker,” she says.
Dishner has had two doses of vaccine plus two boosters. Each time, she had what regulators consider to be mild reactions, including a sore arm, slight fever, nausea, and body aches. Still, there’s some evidence that the newest booster, which protects against some of the later variants, could help people like Dishner in several ways, says Ziyad Al-Aly, MD, a clinical epidemiologist and prolific long COVID researcher at Washington University in St. Louis.
“A bivalent booster might actually [help with] your long COVID,” he says.
There may be other benefits. “What vaccines or current vaccine boosters do is reduce your risk of progression to severe COVID-19 illness,” Al-Aly says. “You are avoiding hospital stays or even worse; you’re avoiding potentially fatal outcomes after infection. And that’s really worth it. Who wants to be in the hospital this Christmas holiday?”
Each time people are infected with SARS-CoV-2, the virus that causes COVID-19, they have a fresh risk of not only getting severely ill or dying, but of developing long COVID, Al-Aly and colleagues found in a study published in the journal Nature Medicine in November. “If you dodged the bullet the first time and did not get long COVID after the first infection, if you get reinfected, you’re trying your luck again,” Al-Aly says. “I would advise people not to get reinfected, which is another reason to get the booster.”
In a recent review in the journal The Lancet e-Clinical Medicine, an international team of researchers looked at 11 studies that sought to find out if vaccines affected long COVID symptoms. Seven of those studies found that people’s symptoms improved after they were vaccinated, and four found that symptoms mostly remained the same. One found symptoms got worse in some patients.
A study of 28,000 people published in the British Medical Journal found more evidence that vaccination may help ease symptoms. “Vaccination may contribute to a reduction in the population health burden of long COVID,” the team at the United Kingdom’s Office for National Statistics concluded. Most studies found vaccination reduced the risk of getting long COVID in the first place.
Vaccines prompt the body to produce antibodies, which stop a microbe from infecting cells. They also prompt the production of immune cells called T cells, which continue to hunt down and attack a pathogen even after infection.
A booster dose could help rev up that immune response in a patient with long COVID, says Stephen J. Thomas, MD, an infectious disease specialist at Upstate Medical Center in Syracuse, NY, and the center’s lead principal investigator for Pfizer/BioNTech’s COVID-19 2020 vaccine trial.
Some scientists believe long COVID might be caused when the virus persists in parts of the body where the immune system isn’t particularly active. Although they don’t fully understand the workings of the many and varied long COVID symptoms, they have a good idea about why people with long COVID often do better after receiving a vaccine or booster.
“The theory is that by boosting, the immune system may be able to ‘mop up’ those virus stragglers that have remained behind after your first cleanup attempt,” Thomas says.
“The vaccine is almost lending a hand or helping your immune response to clear that virus,” Al-Aly says.
It could be difficult for long COVID patients to make an informed decision about boosters, given the lack of studies that focus exclusively on the relationship between long COVID and boosters, according to Scott Roberts, MD, associate medical director for infection prevention at Yale New Haven Hospital.
Roberts recommends that patients speak with their health care providers and read about the bivalent booster on trusted sites such as those sponsored by the FDA and the CDC. He says long COVID patients should get the latest boosters, especially as there’s no evidence they are unsafe for them. “The antibody response is appropriately boosted, and there is a decent chance this will help reduce the impact of long COVID as well,” he says. “Waiting will only increase the risk of getting infected and increase the chances of long COVID.”
Only 12% of Americans 5 and older have received the updated booster, according to the CDC, although it’s recommended for everyone. Just over 80% of Americans have gotten at least one vaccine dose. Thomas understands why the uptake has been so low: Along with people like Dishner, who fear more side effects or worse symptoms, there are those who believe that hybrid immunity — vaccination immunity plus natural infection — is superior to vaccination alone and that they don’t need a booster.
Studies show that the bivalent boosters, which protect against older and newer variants, can target even the new, predominant COVID-19 strains. Whether that is enough to convince people in the no-booster camp who lost faith when their vaccinated peers started getting COVID-19 is unclear, although, as Al-Aly has pointed out, vaccinations help keep people from getting so sick that they wind up in the hospital. And, with most of the population having received at least one dose of vaccine, most of those getting infected will naturally come from among the vaccinated.
Thomas describes the expectation that vaccines would prevent everyone from getting sick as “one of the major fails” of the pandemic.
Counting on a vaccine to confer 100% immunity is “a very high bar,” he says. “I think that’s what people expected, and when they weren’t seeing it, they kind of said, ‘Well, what’s the point? You know, things are getting better. I’d rather take my chances than keep going and getting boosted.’ “
One point — and it’s a critical one — is that vaccination immunity wanes. Plus new variants arise that can evade at least some of the immunity provided by vaccination. That’s why boosters are built into the COVID vaccination program.
While it’s not clear why some long COVID patients see improvements in their symptoms after being vaccinated or boosted and others do not, Al-Aly says there’s little evidence vaccines can make long COVID worse. “There are some reports out there that some people with long COVID, when they got a vaccine or booster, their symptoms got worse. You’ll read anecdotes on this side,” he says, adding that efforts to see if this is really happening have been inconclusive.
“The general consensus is that vaccines really save lives,” Al-Aly says. “Getting vaccinated, even if you are a long COVID patient, is better than not getting vaccinated.”
Jackie Dishner, Phoenix.
Ziyad Al-Aly, MD, director, Clinical Epidemiology Center, Washington University, St. Louis; chief of Research and Development Service, Veterans Affairs St. Louis Health Care System.
Nature Medicine: “Acute and postacute sequelae associated with SARS-CoV-2 reinfection.”
The Lancet eClinical Medicine: “Impact of COVID-19 vaccination on the risk of developing long-COVID and on existing long-COVID symptoms: A systematic review.”
The British Medical Journal: “Trajectory of long covid symptoms after covid-19 vaccination: community-based cohort study.”
Stephen J. Thomas, MD, director, Institute for Global Health and Translational Science, Upstate Medical University, Syracuse, NY.
Cell Death & Differentiation, “Long Covid: where we stand and challenges ahead.”
Scott Roberts, MD, associate medical director, infection prevention, Yale New Haven Hospital, New Haven, CT.
Yale School of Medicine Iwasaki Lab: “Immunology of long COVID.”
FDA: “Covid-19 Bivalent Vaccine Boosters.”
CDC: “Stay Up to Date with COVID-19 Vaccines Including Boosters,” “COVID Data Tracker, COVID in Your Community,” “COVID Data Tracker, COVID-19 Vaccinations in the United States.”
The New England Journal of Medicine: “A Bivalent Omicron-Containing Booster Vaccine against Covid-19.”
bioRxiv: “Improved Neutralization of Omicron BA.4/5, BA.4.6, BA.2.75.2, BQ.1.1, and XBB.1 with Bivalent BA.4/5 Vaccine.”
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