The meaning of the term “fully vaccinated” is changing. I’m really hoping that our federal guidelines, our local ordinances and our employer mandates keep up with that change. But until they do, you need to do something very safe, very effective and VERY important.

If you are over 18 and more than six months out from your second Pfizer or Moderna COVID vaccine (or more than 2 months out from your J&J shot), you absolutely should get a booster as soon as you can. As far as I'm concerned, that's the new definition of "fully vaccinated".

PLEASE don’t think about this in a political context. Please don’t think about this in terms of what you had read last Spring, or what some authority figure told you months ago, or what you think the world owes us after almost two years of the pandemic.

Every day we learn more about the virus and the efficacy of our response to it. Making decisions about how to deal with COVID is like making decisions about how to dress for the weather. A sunny day last June doesn’t mean that you go out in shorts during a December snowstorm. What the CDC and the FDA do - and what you should do - is watch things. Specifically, watch the risk of transmission

in your community (something that can be calculated based on how much COVID there is around, how many people are vaccinated, and how many new cases there are each week). You can also watch for new developments as we track immunity after vaccination. Will the COVID vaccines be like other long established childhood immunization protocols, with a set plan of three shots for everyone? Or will they involve boosters at regular intervals? No one really knows the answer to that now. But we can still make good decisions with the information that we have.

It has been known for a while that antibody levels, reduction in transmission, and protection from infection (both asymptomatic and life threatening) drop off with time after vaccination. This also happens after natural infection. The result of this is that breakthrough infections are becoming more common, and for some people, more serious. Colin Powell - who was in his 80s and who had a type of cancer that affects the immune system - died of COVID the week that he was scheduled to get his third dose. This underscores the importance of boosting as it has become clear that protection rebounds quickly with a booster shot.

Most of us aren’t in such a high risk group. Even with fading immunity after six months, the risk of hospitalization or death is still significantly lower if you are vaccinated. It's also important to remember that levels of antibodies aren't the whole story - the immune system is complex. A billion years of evolution has produced a pretty impressive system, and much of our current booster research is about intervals - finding the right time to provide your B-cells with more practice.

But what you should NOT do is tell yourself “I’m fully vaccinated, and that’s that”. Even if your employer doesn’t mandate a booster after 6 months, you absolutely should get one. Get one for yourself - as immunity wanes, breakthrough infections become more common and more serious, and the chance of having lingering symptoms ("long COVID") start to increase. Get one for people at risk in your community. The elderly or those with immune system problems can’t completely rely

on their own vaccines, and as your own immunity drops, you become more likely to spread COVID without even knowing it. And get one to stop the pandemic. The more cases there are - even asymptomatic cases - the more the virus evolves. Someday there may be a variant that isn’t controlled by our vaccines at all.

I’m worried that things are trending in the wrong direction right now. Cases had been falling, and now they are rising again. We are heading into winter, where people are much more likely to be indoors together, in public, and maskless. Last winter, before we had vaccines and good treatment for the infected, fear really limited a lot of that behavior.

That isn’t the case now. People are fed up with the pandemic and are ready to return to normalcy. They have mostly complied with vaccine mandates, and now they feel that they are owed something. There doesn't seem to be much political will for an employer booster mandate. Restaurants aren’t likely to quietly go along with moving the goalposts. If the city redefines “fully vaccinated” to mean boosted after 6 months, that’s going to deprive them of a big chunk of their customers as the cold weather makes outdoor dining unappealing.

But the thing about a pandemic is that COVID doesn’t care about any of that. There is no guarantee of a happy ending. No one can mark a date on the calendar when this will all be over. So it’s up to us to do what we can to protect ourselves, to protect our communities, to protect those at risk, and to work to put this virus in the rear view mirror.

I have always required my staff to be fully vaccinated to keep themselves, my patients and their families safe. In my office, that now means a booster after 6 months. In making decisions about who to socialize with indoors, I use this new definition of "fully vaccinated". When I last wrote, I told you how happy I was that my 8 year old has had her first shot - I'm just as happy that my older kids have had their boosters. As you can see in the photo above, I vaccinated one of them myself!

I know that we are all sick of this. But we have no smart way forward other than making good decisions together. Let's work in good faith and beat this thing.

#stopthespread