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  • Writer's pictureDr. Bow Tie


So you've received two doses of the COVID-19 mRNA vaccine (or one dose of the J&J adenovirus vaccine) and you've been figuring out when you can afford to sacrifice a couple of days of your precious free time (that's not sarcastic, not enough people get time to be away from work to get a vaccine and deal with its reactogenic effects) to get your booster/third dose (or maybe you’re not vaccinated at all), when suddenly...

You get a sore throat, or a cough, or you wake up feeling like you've been run over by a truck...

Or your family member texts you to inform you that even though they're vaccinated and you both took as many precautions as you could (short of not hanging out at all)...

Or you hear from a friend or an Instagram post that there has been outbreak of cases of COVID-19 from a place or event that you were at...

Or you're just following the recommendations of testing before you go out and a few days after you gather and maybe you're the first of your group to test yourself...

...And you test positive for COVID-19. You see that second line on your rapid test and your heart sinks. You swear under your breath because you know you have to tell some folks. You contemplate getting a PCR just in case you're part of the 0.1% of false positives. But you know that the rapid is more likely to detect active infection and the PCR, while the gold standard, has a slightly greater propensity for false negatives. So you sigh and prepare to isolate.

You contact your PCP, if you have one. Or you contact the department of health to look for guidance. Or you message your medical friend who writes long-ass blog posts or makes informative TikToks to see if he/she/they have advice.

Maybe you are asymptomatic and you stay that way, so you test at day 5 and are negative because you've rapidly cleared the virus (thanks, vaccines!), so you're able to go back to work with a mask on.

Maybe you stay asymptomatic but you test at day 5 and are still positive, so you finish out your 10 days. Maybe you’re unvaccinated, so you’re out for 10 days regardless.

Maybe you're symptomatic, but your symptoms are mild and you get through it at home. You get a pulse oximeter and a thermometer but despite that awful hacking cough, your oxygen levels stay high and your fevers stop by day 10 and you no longer need the acetaminophen you've been using.

Maybe you're symptomatic but your symptoms are "improving" by day 5 and you work in healthcare so you prepare to go back to work because your boss says so.

Maybe you go through your PCP or a nearby hospital and get a monoclonal antibody treatment (which is more difficult now because of the multiple mAbs we were using, only sotrovimab has been shown to have effect against Omicron and it's getting a bit scarce at times).

Hopefully you don't end up needing to go to the emergency department because you're getting short of breath or your oxygen levels are dropping.

Hopefully you do have a support system who brings you food or checks on you in some other way, wearing a mask and limiting their time to avoid exposure and contagion.

Hopefully the whole thing passes quickly and you go back to normal. And then a question pops up.

Do you still need a booster?

The answer is, not necessarily right away. You have what we call hybrid immunity - you've received two doses of a vaccine and then you got a serving of infection-mediated immunity.

We have seen that infection-mediated immunity alone is unreliable (no matter how many times people try to claim that it's "enough" or "superior") - the data continues to show that it's too variable, and often disappears after roughly 90 days (give or take), and it hasn't stood up to newer variants based on older cases because it doesn't create the right type or amount of memory cells.

We have seen that vaccine-mediated immunity from two doses is good against original COVID and the other variants up through Delta, but reduced against Omicron.

We have seen that hybrid immunity is superior to vaccine-mediated immunity because it almost acts like a booster. It can be costly depending on how your infection goes, but it's helpful.

And we have seen that three doses of the vaccine increase your immunity against Omicron to levels similar to what it was against Delta.

As Dr. Risa Hoshino says, “Science didn’t ‘lie to you’. Shots were initially working very well against infection with the OG virus. But then NOT ENOUGH ppl got vaccinated & so new variants emerged.” But we know that even if they don’t protect against infection as much now, vaccines still protect against severe disease, hospitalization, and death.

So what if you get your hybrid immunity from an Omicron variant infection (you may not know whether it's Omicron for sure, but that does seem to be most common these days)? Do you still need a booster?

For the first 1-3 months, there may not be much of a rush as your immune system still has the memory of Omicron fresh. And if you received monoclonal antibodies, you DO need to wait 90 days based on how we have studied them and what we know so far.

However, if you did not receive monoclonal antibodies, there is also no reason to wait on your booster. As soon as your quarantine period is done and your symptoms have resolved, you're free to get your booster and solidify that immunity, create those memory immune cells that will last longer than your infection/mediated immunity and stand a better chance of protecting you from future variants that may (will) come until we can get enough of the country and the world vaccinated to control COVID-19 definitively.

You don’t have to wait very long to contribute to the efforts to eradicate this virus, even though you know that can take years (as it did for smallpox and is still taking for the reachable goal of eradicating polio). You read an excellent tweet thread by epidemiologist Ellie Murray that I share below so you know that “endemic“ is a word being thrown around these days with an oversimplified and somewhat incorrect definition, because people take “endemic” to mean “easier” which it is not, given the vigilance and continued mitigation measures that will still need to be taken at times when infections surge.

You know that you probably have at least one more long blog post to look forward to (or avoid) this week because I have even more myths and misconceptions to address.

You know that I’m gonna end this with the hashtag #VaccinateAndMitigate in the hopes of steering away from the misunderstanding that vaccines are the magical be-all-end-all for this pandemic and that it is going to be a multilayered effort involving masking, distancing, hand hygiene, global health/vaccine equity, and at times limiting gatherings or travel - a point that I and many others let fall by the wayside for some time because we did focus on collective vaccination so much (because they are the crux of the plan).

And you know I welcome your questions.

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Dr. Bow Tie

I’ve just read my first and your most recent post. Thanks for your insights and commitment.

My question is this;

I've been trying to understand whether a person could've had Covid with no or mild symptoms weeks or months ago and then got tested positive recently. Could a person be positive from way back then? Or is the test registering only recent infection? And once you've had Covid you will always test positive on a test?

Dr. Bow Tie
Dr. Bow Tie
Jan 10, 2022
Replying to

Hi there, thanks for reading! So there are a couple of reasons you may test positive. Some folks do test positive for weeks (somewhat rare), but if you had no symptoms or whatever symptoms you had were mild, even that seems remote. Rapid antigen and lateral flow tests detect a specific antigen on the viruses (in this case a nucleocapsid protein or other specific protein) and PCR detects viral DNA, which are generally only present if the virus is active. Mileage varies, but generally speaking, people stop testing positive after active infection ends. Antibody tests will remain positive for some time, though infection-mediated antibodies often fade after 2-3 months. Does that help?

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