An ongoing dialogue on HIV/AIDS, infectious diseases,
November 12th, 2021
Time to Simplify the COVID-19 Vaccine Policy — Authorize a Booster Dose for Anyone Who Wants One
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:
Important paper, just published @ScienceMagazine, on waning vaccine effectiveness among >780,000 US Veterans over time and during the Delta wave. Across all ages; J&J vaccine had the most decline; reduction protection vs deaths too (Figure at right) https://t.co/onRQY9XAl0 pic.twitter.com/nj6zG3Hedw
— Eric Topol (@EricTopol) November 4, 2021
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.”
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.