One month into the rollout of the new bivalent booster shots––which protect against the original strain of the virus as well as two Omicron variants––only four percent of Americans have received the updated boosters. President Biden said “the pandemic is over” on national television last month. But epidemiologist Jennifer Nuzzo says that his second comment––“we still have a Covid problem”––didn’t get the same type of airtime. Nuzzo worries that Americans may only have heard the first part of Biden’s comment and are left “not understanding that they still need boosters and could benefit from them.” 

Nuzzo spoke to the Institute for Public Accuracy about how waning immunity and low booster uptake have led to a situation in which Americans over the age of 65 are still quite vulnerable to severe illness and death from Covid-19 infections.

JENNIFER NUZZO; jennifer_nuzzo@brown.edu, @JenniferNuzzo
    Nuzzo is a professor of epidemiology and director of the Pandemic Center at Brown University School of Public Health. 

Although we are still lacking “concrete data on the breakdown” of Americans who have received the newest boosters, we do know some “big themes. We still have upwards of 300 deaths per day,” Nuzzo said, “and when you look at who makes up those statistics, the majority of deaths are in people over the age of 65––and increasingly, over the age of 75. Age has always been the biggest risk factor. But over the course of the pandemic, deaths have increasingly been within that group of people over the age of 75.” That shows us what we need to do, Nuzzo said, “to address these unacceptable high numbers of deaths.” 

She added: “America is under-boosted. When I last looked at the data, 30 percent of people over the age of 65 hadn’t gotten a third dose of the vaccine, and 60 percent hadn’t gotten a fourth dose. By and large, this group is vaccinated––but why aren’t they getting up-to-date boosters? If they’ve received the third but not the fourth shot, it could have been more than a year since their last vaccine. I’m particularly worried about people over the age of 65; we need to get these folks boosted. If nothing else, we need to get people over the age of 65 up to date.” 

Nuzzo said there are several reasons booster uptake may still be low. There may be a shortage of vaccines; “there are spot shortages of the Moderna vaccine, which may be particularly effective because it has a higher concentration of mRNA than the Pfizer vaccine does. Anecdotally, I’ve also heard that some elderly people don’t think it’s needed. I have friends who are lamenting that their parents haven’t gotten boosted. Some elderly folks may also be worried about being alone after getting boosted, if they develop symptoms.” 

Besides boosting, Nuzzo says that we need to increase testing. “Even with the bivalent booster, I suspect people will still get infected,” she said. “But if they’re not feeling well, they need to get tested. That way they can start Paxlovid early, which can keep them out of the hospital. But that needs to be done early on in illness––you can’t wait it out or wave off early cold symptoms. Right now, unfortunately, people coming to the hospital may be getting tested for the very first time.” 

Since the start of 2022, testing has also increasingly been done at home. Nuzzo is concerned that not everyone can afford at-home tests. Further, it’s possible that when an older person is sick, they won’t want to or be able to “drive to CVS and then get tested… and even then, test-to-treat pharmacies,” which can immediately prescribe Paxlovid to those eligible, “aren’t available in every community.” Nuzzo insists that “everyone at risk needs a Paxlovid Plan.” Paxlovid use is lower in the highest age group than it is in younger groups. “We see an under-prescribing of Paxlovid that unfortunately may include people who are at highest risk of severe illness.” 

Some of that underprescribing, Nuzzo suggests, may be due to logistics, such as obtaining prescriptions. But Nuzzo has also heard from clinical colleagues that doctors are worried about Paxlovid rebound (where those treated with the antiviral have Covid symptoms that recur after they complete the course of the medication). “For less high risk patients,” she said “rebound is a real consideration. But for older or elderly adults, the risk of severe illness is the highest priority––and there’s a compelling case for using Paxlovid for avoiding severe illness.” Other doctors may be concerned about interactions between Paxlovid and other drugs that patients are taking. But Nuzzo said patients can oftentimes negotiate, or take a pause on their other medications, to accommodate Paxlovid in their regimen.

Nuzzo was pleased that the White House has recently announced it will be working with nursing homes, which are still “a place of concern. Twenty percent of deaths are still coming out of long-term care facilities. Those are high-risk patients with high-risk exposures.” On her to-do list, she said, is to take care of nursing homes and senior living establishments. 

“We have tools to keep older Americans out of the hospital––but we’re underutilizing them.”