Welcome to the June 2023 Newsletter for

Santa Monica Primary Care.

In this issue we will cover the upcoming vaccination season.

Fall 2023 COVID Booster (Bivalent 2.0)

With very little fanfare, Los Angeles County’s COVID-19 Emergency ended on March 31st – with the major impact being the closure of County-run testing facilities. But beyond that, not much
changes. An indoor masking mandate was lifted 13 months ago and face covering recommendations for the general public ended two months ago. In healthcare settings, masks continue to be required for healthcare workers providing direct patient care or working in patient care cares. This, however, is a Los Angeles County only requirement as at other healthcare settings in California, no masks are required whatsoever

It was certainly reasonable for the County to close testing sites as weekly testing rates are the lowest they have been (at 148 tests per 100,000 population) since May of 2020 (Figure below). At their maximum, 2745 tests per 100,000 were performed the week ending 1/11/2022.

Smoothed SARS-CoV2 Daily Testing Rate (per 100.000 population): Los Angeles Country

Free testing remains available at LA County Public Health clinics

Seasonal COVID Incidence and Prevalence

The Los Angeles Times offered this outstanding turn of phrase when reflecting on the lifting ofthe COVID Emergency:

“But just as March 2020 is now indelibly etched in our collective consciousness
— a watershed moment when daily life screeched to a — March 2023 may be
remembered as when COVID-19 officially went from top of mind to back of mind.”

From my perspective, I was concerned that we would experience another January surge as we had in 2021 and 2022 but that never materialized (Figure below)

Smoothed Daily Incident Case Rate (Per 100,000 population) of SARS-CoV2: Los Angeles Country, California for 2020(Blue),

We are now in our current and expected Spring lull in cases, seen in all years of the pandemic -although 2020 should be interpreted cautiously given that we were under shelter-in-place orders.

Current prevalence rates (active cases per 100 population) are the lowest they have been at less than 0.1% – so fewer than 1 case per 1000 individuals – since October of 2022 (Figure below).

Estimated Prevalence Rate (per 100 individuals) of SARS-CoV2: Los Angeles Country, California

Seasonal Flu Shot for 2023/2024

One common mantra that has been repeated throughout the pandemic is that of “more cases, more hospitalizations, more deaths.” This is a pattern currently holding in the inverse with death rates also now at historic lows as case rates are at seasonal lows as well. However, in 2023 with early detection from accurate home testing and widespread availability of Paxlovid, mortality rates now stand at 0.02 deaths per day per 100,000 population (equivalent to 2 deaths per day in LA County, with 10 million people). The last time mortality was this low?

The week of March 17th, 2020.

The figure below is a log transformed graph which shows more clearly just how much mortality rates have dropped

Smoothed Daily Mortality Rate (Per 100,000 population) of SARS-CoV2: Los Angeles Country, California

RSV Vaccination for those over 65

Similar to the County’s experience, we too have seen a massive decline in cases since
November 2021 when we had 29 new cases (and 5 repeat infections). Thus far in April we have had only 3 cases (2 of which were repeat infections)

Total COVID-19 Cases and Repeat Infections by Month in 2022/2023: Santa Monica Primary Care

Timing of vaccinations

This past week, the FDA amended the terms of its Emergency Use Authorization (EUA) for the Moderna and Pfizer bivalent boosters, permitting individuals 65 and older and those with underlying immunocompromise to have an additional dose (providing that it has been 4 months from the last).

In conversations with patients about this new recommendation, I’ve found myself clarifying a few aspects of the FDA’s communication:


  1. This is not a “new” booster, it is a new recommendation. The booster is identical to that originally authorized at the end of August of 2022.
  2. The Bivalent booster contains mRNA components from the original strain of
    SARS-CoV-2 as well as from the BA.4/BA.5 omicron variants. The BA.4 and BA.5 variants have not circulated since the Fall of 2022
  3. This recommendation brings the US more in line with the UK and Canada. In the UK, they have referred to the second bivalent booster as a ‘top off’ for vulnerable populations.
  4. Fall 2022 bivalent booster uptake was far higher in the UK than the US. In the UK, 65% of those 50 and over received the bivalent booster, and >80% of those over 70 received the booster. In the US, only 42% of the population over 65 had a booster dose. So some of the rationale for recommending a second bivalent booster may, in fact, be to encourage people simply to get their first.
  5. The general expectation is that there will be a new booster available in the Fall of 2023 which would be updated for circulating variant(s) at that time and also coincide in timing with an annual flu shot
  6. For now there is little compelling reason if one is young and healthy to have another bivalent booster. Individuals that are older (65 and above) with comorbidities or any immunocompromise could think about one at this point, with the context that cases and deaths are currently at historic lows.

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