November 12th, 2021

Time to Simplify the COVID-19 Vaccine Policy — Authorize a Booster Dose for Anyone Who Wants One

Medlar, Poppy Anemone, and Pear. From The Model Book of Calligraphy (1561–1596).

At this point in the post-vaccine era of the pandemic, we all know people who have had COVID-19 despite being fully vaccinated. Patients, coworkers, family, friends.

The reason these breakthroughs are so common is now obvious — our initial vaccine strategies did not provide durable protection against infection. And recognition of this fact prompted the FDA and CDC to recommend a booster dose for people at high risk for severe COVID-19, and for people at high risk for exposure to the virus. Six months after the second dose is the recommended schedule.

Based on my occupation, I’m one such eligible person. (Thank you, Dr. Walensky.) But shouldn’t everyone have access to this benefit? I’d strongly argue yes.

Because at this point, it’s not just one study showing the vaccines are losing their effectiveness over time — it’s multiple studies, conducted all around the world in highly diverse settings and using different vaccines. As an example, let’s go with this large recently published paper because the effectiveness curves tell the story so clearly:

While the vaccines continue to be way better than no vaccine in prevention of serious COVID-19, hospitalization, and death, they’re slowly losing their effectiveness in these metrics too — especially among high-risk individuals.

Let’s also state the obvious:

Some people who get “mild” breakthrough infections get pretty sick, and feel lousy.

They have fevers, chills, cough. They lose their sense of smell and taste. They are profoundly fatigued. They’re out of work, or school, and have to isolate from their family and friends.

In other words, though classified as “mild” cases for epidemiologic purposes, they don’t feel so mild to people who get them.

In addition, a symptomatic case — breakthrough or not — can pass the virus on to others, which is especially worrisome for the not insignificant proportion of the population who are immunocompromised and don’t get full protection from the vaccines.

Which is why, while watching our vaccine experts and public health officials and the FDA and the vaccine manufacturers debate over who should and who should not be eligible for a 3rd dose of the Pfizer and Moderna vaccines, I’ve come to the straightforward conclusion that it should be any adult who wants one.

And I’d recommend that strategy for pretty much 100% of people who ask me what they should do — just as I’d advise an annual flu shot. After all, influenza also causes a nasty respiratory viral infection that most of the time does not lead to hospitalization or death. We still want to prevent the flu in young healthy people, don’t we?

Another benefit of advising boosters for all is that it will simplify the messaging about what we advise our patients, which is now way too convoluted. Allow me to quote (with permission) primary care physician Dr. Lucy McBride, who expressed frustration with the conflicting messages she’s been getting from the press and the CDC. She wonders what to tell her booster-ineligible patients now:

My concern is over the messaging and about the lack of clarity from CDC about what our overall goals are. I think it would improve trust in our public health institutions if they just came out and said, “Look – the vaccines still work great in preventing hospitalization and death, but we are worried about rising case numbers in the upcoming winter months and would like to reduce infections as much as possible.”

Agree 100%.

Some worry that authorizing boosters for all locks us in to repeated cycles of COVID-19 vaccination in an endless cycle of shots. But the reality is we just don’t know enough yet to make this statement. It could be that just this third shot is required for durable protection in most people. Or, alternatively, that periodic boosters will be required. Or something in between, based on community risk of disease, age, other risk factors, or a simple test to assess who is protected and who isn’t, or some other metric.

In short, we just don’t know — best to acknowledge that up front.

Additionally, some argue that giving a third dose distracts us from getting the unvaccinated people their first dose, or that doing so depletes the vaccine supply from global distribution to places that have limited access, or that this will increase vaccine hesitancy, or that some very small fraction of those who get vaccinated will have an adverse event, or that there are other non-policy prevention strategies that need reinforcement.

These are legitimate points to raise (artfully done by colleagues of mine) in discussions about where to focus our efforts in public health. We should welcome these debates, but not lose sight of the fact that these efforts can be done in parallel. Continuing to advocate for first-time vaccination for the unvaccinated and simultaneously offering boosters to adults are not strategies that conflict. California and Colorado already have adopted this approach.

So as we head into the winter, with cases increasing again — and Europe providing a potential warning of what we’ll be seeing soon in the USA — it’s time to just make these third doses available to all who want them.

Because getting this viral infection stinks. And preventing it is in everyone’s best interest.

8 Responses to “Time to Simplify the COVID-19 Vaccine Policy — Authorize a Booster Dose for Anyone Who Wants One”

  1. Sky says:

    Great post as always. The definition of terms are not well defined in this debate. It does appear that circulating nAbs correlate with viral infection. Boosting reliably increases nAbs for a limited time unless exposed. The hyper-inflammatory phase of this illness that is responsible for most hospitalizations and certainly the deaths in non-immunocompromised persons may have a different correlate of protection. The bar for calling a case severe is low enough that individuals with a viral infection and not the hyper-inflammatory phase can easily meet that criteria. Clinically, i see that vaccinated individuals retain the ability to prevent the hyper-inflammatory phase and that type of severe COVID-19 despite waning nAbs. The severe “breakthrough” cases that I see in practice are in the immunocompromised who don’t respond to vaccinations and those with risk factors that would make any respiratory viral infection potentially deadly. We should define our terms of this disease better for this debate: Viral infection, Severe viral infection, Viral infection with hyper-inflammatory syndrome, Viral infection with post-acute sequelae.
    Welcome your thoughts…

  2. Loretta S says:

    I could not agree more. If an adult had the series 6 months ago or more, let them get a booster. Keep the message simple. My local county health department has taken the approach that they won’t quiz people about whether they are eligible according to CDC rules. They have a very efficient center set up that operates 5 days a week (including Saturdays) and all one has to do is walk in, present ID to show you’re a resident of the county, and you get the vaccine. CDC vaccination cards showing prior doses are welcome, but not necessary to bring. Just did this yesterday and it was in and out very quickly.

  3. Mimi Breed says:

    Common sense. Thank you.

    In mid-September, when the agencies were still making up their minds, I happened to be traveling in my home (red) state, where a local pharmacy was liberally offering boosters. I answered a pro forma questionnaire (the “right” way, as my brother coached me), showed my double-vax Moderna card, and took the Moderna booster. I didn’t technically qualify, but I’m old with multiple comorbidities and live with unvaccinated toddlers. No brainer.

  4. Shishir Gokhale says:

    I do not agree with the idea of universal boosters (how many? how often?) for following reasons:

    1. Aim of vaccines is to prevent hospitalisation, severe disease and death which is being achieved in 98% of two dose vaccinated people. They do not need booster.

    2. The breakthrough infections are in small number of vaccinated people, milder and no threat to life. Vaccine has served its purpose.

    3. Success of vaccine is NOT dependent on circulating antibody titre but on the over all immune and modulated inflammatory response based on innate immunity, T and B cells, killer cells, memory cells etc which persists for long duration and gets activated on reexpoure. No booster required for this.

    4. Boosters of same vaccine in non responders is akin to flogging a tired horse. Making same mistakes and expecting different outcome is foolish.

    5. The logistics of universal boosters is mind boggling and will benefit only vaccine industry which has already profited by more than 30 Billion $ in one year. The funds could be better utilised.

    6. The possible side effects of vaccination will be compounded and bring vaccines into disrepute. I draw attention to following paper.

    https://pmj.bmj.com/content/early/2021/10/06/postgradmedj-2021-141119?utm_source=adestra&utm_medium=email&utm_campaign=usage&utm_content=monthly&utm_term=11-2021

    7. Boosters for well-off and not a single dose for most vulnerable will enhance social inequity within the society and countries.

  5. Neil S says:

    Why are we still talking about “vaccinated” people as if all vaccines are the same? When it comes to waning immunity, there’s clearly a significant difference between the original Moderna series and the single J&J dose, and seemingly even an important difference between Moderna and Pfizer initial series. If Moderna were the only vaccine on the market, would we really be considering 6 month boosters? And why hasn’t Pfizer done any controlled trials comparing a higher dose and longer interval of its own vaccine vs its current regimen? Could it be that if you make a light bulb that lasts for 10 years people won’t have to buy so many light bulbs?

    • Shishir Gokhale says:

      Very apt comment “Could it be that if you make a light bulb that lasts for 10 years people won’t have to buy so many light bulbs?”

      Unfortunately the vaccine industry is intentionally making vaccines which will NOT LAST 10 years so they can sell more vaccines and reap profits.

      This is the business model promoted and followed by Apple and Microsoft in IT world, unfortunately being copied in health sector too. Sad state when profit precede health and safety.

  6. Kimon Zachary says:

    I agree completely. The data are sufficiently compelling, and the epidemiological trends are heading in the wrong direction, even in highly vaccinated communities. I suspect adolescents should receive boosters too, though we’ll see what the Israeli experience (again!) tells us about that.

    The points about devising a more effective dosing strategy for the primary series are well taken, but 1) we need protective immunity ASAP in the setting of high community transmission, and 2) that train has already left the station for most adults in most high- and many middle-income countries.

  7. Gerry Creager says:

    “The best indicator of another man’s intelligence is how much you agree with him.” Anon.

    I saw Eric’s Tweet about the same time I was reviewing similar data. Listening to the concerns about providing boosters to all who wanted them was what leapt to mind for me. Would that we could convince more of our citizenry to get to the fully-vaccinated mark in the first place.

    That said, one issue raised with offering boosters for all was that we could, instead, have a bigger impact by vaccinating the world. I happen to support the idea that we need to engage world leaders with the importance of widespread vaccination, with safe and really effective agents. Perhaps I’ve allowed personal bias to creep in but I’ve not personally seen sufficient information on the Chinese or Russian offerings to have an opinion about where those fall in “safe and effective”. What I’m trying to say, however, is it’s time to focus America’s industrial prowess on producing safe and effective mRNA vaccines for the world. Now.

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HIV Information: Author Paul Sax, M.D.

Paul E. Sax, MD

Contributing Editor

NEJM Journal Watch
Infectious Diseases

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