A guide to this fall’s vaccine options

We all feel vaccine fatigue.

If you’re like many Californians, you rushed out in the spring of 2021 to get two COVID-19 shots. That was followed by a third “booster” shot in the fall. When a new and improved vaccine was offered in 2022, you might have gotten that, too.

Now another shot will soon be available. Should you get it? The answer: It depends.

While young people are at lower risk of severe illness than elders, “most people are under-vaccinated now. Which means our immunity is way down,” unless you were hit by this summer’s wave of infection, said Dr. John Swartzberg, clinical professor emeritus of infectious diseases and vaccinology at UC Berkeley.

Even as we grow weary of sore arms, viruses continue on their merry way. Evolutionarily, they’re speed demons. New lineages of SARS-CoV-2 are constantly adding mutations that give them a competitive edge. Meanwhile, our antibodies fade — taking with them important protection.

Soon after the CDC’s Advisory Committee on Immunization Practices meeting on Sept. 12, a new and improved shot will be unveiled. It’s a better match for what’s out there. It comes in the nick of time, as the amount of virus present in California’s wastewater is climbing to its highest level since January, causing a worrisome uptick in hospitalizations. The seven-day average positivity rate for COVID tests in California reached 14% as of Friday, among the highest recorded throughout the pandemic.

This vaccine offers the most help to people over age 60, who are at greatest risk of severe illness and death. Younger people, who are at lower risk, benefit less from booster shots, research shows.

And COVID isn’t this autumn’s only health threat. Two other deadly respiratory viruses — flu and Respiratory Syncytial Virus (RSV) — are about to make their annual seasonal entrance.

There are vaccines for all three of these infectious diseases, for the first time in history.

Rather than three trips to the doctor’s office, can you get all injections at once? It’s not recommended. While it’s safe to get the COVID and flu vaccines during the same visit, there’s less experience with RSV. So experts recommend timing the RSV vaccine at least two weeks before or after the other shots.

This is how Swartzberg, age 78, is planning his vaccinations: RSV in September; COVID-19, late September to early October; and flu, late October to early November. That schedule takes advantage of their optimal effectiveness, and covers him throughout the season, he reasons.

Here’s a summary of additional advice from Swartzberg, UC San Francisco infectious disease expert Dr. Monica Gandhi and others:

COVID-19 vaccine:

An updated vaccine formula will help protect against Omicron XBB.1.5, the circulating strain at the time the vaccine was being designed. Although two other Omicron strains — EG.5 and FL.1.5.1 — are now dominant, new research shows that this new shot is still a good match, said Gandhi.

It’s unknown whether it works against a new hyper-mutated subvariant, BA.2.86, which has a worrisome total of 36 mutations in its spike protein. It hasn’t yet gained a toehold in the United States, and we don’t know how transmissible it is.

If it does become established, the new shot won’t be as helpful, because it is more distantly related. Antivirals like Paxlovid would still work. While there’s no reason for alarm, “It’s something to be watching,” said Swartzberg.

Who should get the booster? The CDC will almost certainly recommend its use in people who are at greatest risk of illness or death from infection: those over age 65 or immunocompromised.

The cost-benefit may be less certain for people who are younger, healthier and who already have received prior versions of the vaccine. Although their immunity has waned, they are still protected against severe illness.

When should you get it? If your last shot was four to six months ago, your immunity is waning. The new shot — from Moderna, Pfizer and Novavax — will likely be ready by mid-September.

But if you get the shot within six months of your previous vaccination or a recent episode of COVID, you won’t get the full benefit. High levels of circulating antibodies from the previous boost may limit the added protection of another booster, said Gandhi. One study showed that getting a booster two months after a recent infection actually reduces the response.

“It’s that sweet spot you’re aiming for,” said Swartzberg.

Although COVID cases are climbing now, experts say it may be best to mask up and wait for the new vaccine, if possible. It’ll be the best match for the virus. Remember to allow two weeks to be protected from a shot. Your immunity will still be strong when cases are expected to climb further in the winter.

RSV vaccine:

For the first time, a vaccine is available for infants, toddlers and older adults. Two manufacturers, GSK and Pfizer, say it offers 82% to 86% protection against severe illness.

Who should get it? RSV causes mild cold symptoms in most people but kills between 6,000 to 10,000 infants and older people every year.

For elders, there’s no blanket recommendation. Rather, the FDA says that people age 60 and older “may” get them based on “shared clinical decision-making.” That means you need to ask your doctor.

There is a different RSV vaccine, based on a monoclonal antibody, for all infants up to 8 months old and for a smaller group of children ages 8 to 19 months old and who are severely immunocompromised or at high risk for severe disease.

There also is a vaccine for pregnant women that provides them with antibodies to pass along to the fetus, protecting newborns. While it has been approved by the FDA, it must still be recommended by the CDC, so it’s unclear when it will become widely available.

When should you get it? RSV is a fall-winter virus, so get the shot as soon as possible. It’s already available and protection is likely to hold up all winter.