Medical Examiner

The Case Against Boosters

This isn’t the kind of protection we need right now.

A woman wearing a mask receives a vaccine from a health care worker.
Eitan Abramovich/AFP via Getty Images

You could be getting another coronavirus vaccine in time to ring in 2022. Wednesday, the White House COVID task force recommended that all vaccinated adults receive a third “booster” dose of the Pfizer or Moderna mRNA vaccine eight months after their second shot. Assuming the Centers for Disease Control and Prevention and the Food and Drug Administration sign off on the plan, boosters will begin on Sept. 20.

The urge to announce something is understandable. The delta-fueled surge is filling hospitals and setting back hard-won attempts at normalcy. Even among the vaccinated, it seems like everyone is back on the personal-risk-calculus roller coaster. However, it’s not clear that deploying boosters right now makes epidemiological—or ethical—sense.

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Even given unsettling anecdotes of breakthrough infections, the vaccines at their regular, original dosing have worked incredibly well. They prevent serious disease and death for almost everyone—even for those infected with the delta variant. At Wednesday’s press briefing, the COVID task force didn’t provide any data that substantially changes that. Although there’s been a slight dip in protection for severe outcomes—whether due to the delta variant, increased exposure during socialization, or waning immunity isn’t clear—the new data suggest vaccines remain 90 percent effective against hospitalization. Data from the U.K., where delta has been circulating for some time, and where hospitalizations among the vaccinated remain low, is also reassuring. Epidemiological data from Israel suggests protection against infection wanes significantly, but some experts are not convinced because of the small number of people in the study, among other factors. It might seem alarming that the CDC’s new U.S. data suggests the vaccines are now only 55 percent effective at preventing infection—but the near-term public health goal isn’t to eliminate infections; it’s to eliminate death and serious disease.

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You might reasonably think that boosters would help with that. But the data the White House task force presented to support boosters, however, didn’t really address whether they’d decrease the worse outcomes. They presented no clinical studies that tested whether a third shot decreased hospitalization or death. Instead, they showed off studies that looked at antibody levels. In a brief presentation, Anthony Fauci pointed to four lines of evidence that boosters were useful: that vaccine-induced antibody levels fall over time, that higher antibody levels correlate with higher levels of protection, that higher antibody levels may be required to fend off the delta variant, and that booster doses, well, boost antibody levels. This is all promising news, but it’s far from clear that tweaking antibody levels in healthy adults will keep people out of the hospital. Boosters might make sense for the elderly and seriously immunocompromised—which the FDA already greenlit last week.

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The real issue that America is facing with the pandemic right now isn’t breakthrough infections—it’s infections in unvaccinated people. That’s what’s straining hospitals from Kentucky to Texas, and what caused the entire state of Alabama to run out of ICU beds this week. And boosters are definitely not the best strategy to deal with that. As Eleanor J. Murray and Ruby Barnard-Mayers pointed out in Slate, the mathematics of boosters just don’t add up. In their line of thinking, fully vaccinating 30 million partially unvaccinated people would offer the same benefits to community transmission as boosting 180 million vaccinated people (which is an extremely tall order, logistically). In other words, you’d need to reach six times as many Americans with boosters to have the same effect on transmission of the virus as just getting regular vaccination up. On a global scale, giving additional shots to already vaccinated Americans is profoundly questionable: Vaccination rates in wealthier countries are 100s or 1,000s of times higher than vaccination rates in less wealthy countries. It’s also strategically dumb. Viruses don’t pay attention to political borders, and the more the virus circulates worldwide, the more it will mutate, and the more likely everyone will encounter a variant that is deadlier, is more contagious, or—worst of all—renders the vaccines useless.

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Still, a booster shot isn’t worthless—particularly if you’re talking about a booster shot going into your own arm. Should you get infected, the extra dose might stave off what otherwise would have been a rough week in bed. This is especially meaningful to people whose jobs aren’t very forgiving with missed time, or parents who are juggling child care duties. Psychologically, it just feels good to have another tool to beat back the feeling of powerlessness. If you’re offered a booster, by all means, get it. You’ll probably get some benefit. And importantly, your dose would not have been rerouted to a health care worker in the Democratic Republic of Congo, where 0.1 percent of the population has been vaccinated.

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Ultimately, though, a slim extra layer of protection and assuaging individual anxiety might be about all a booster shot is going to do. In a world where cases are still high and some people are still vulnerable, simple measures such as masks in some public spaces may be merited in the near future—even among those who have gotten three shots. Yes, I’m sick of masks too. But boosters and masks are not mutually exclusive strategies. In fact, as Murray’s math suggests, the best strategy to get rid of masks is to get cases down overall.

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What could actually help do that? There are two things that the FDA should actually be doing to protect Americans—things that would dramatically increase the number of unvaccinated people that get the jab. First, the FDA could fully approve the vaccine. All vaccines are still on the market under emergency use authorization, and up to 23 million Americans say they’ll get the shot once it’s officially approved. And it’s expected that after full approval, businesses will be more inclined to require vaccination of their employees. Second, the FDA could authorize the vaccine for the 28 million kids aged 5–11 as soon as possible. According to the American Academy of Pediatricians, the safety data is already available for the FDA to decide. Instead, the FDA is requesting more data for reasons that make little sense. These two actions would be far more effective than boosters that top off the antibody gas tanks of healthy adults.

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Another announcement that the administration made Wednesday is far more consequential than boosters: The administration will withhold federal funding for nursing homes with unvaccinated workers and will compensate educators whose pay is cut by state or local governments if their schools mandate masks. These policies will be contentious, but at least they are addressing the problem collectively. They’ll also be more helpful than boosters in achieving the ultimate goal that many Americans have personally—being able to cavort with friends and strangers indoors, in public, without masks, and without putting anyone else in danger.

The real issue with boosters is that, alone, they simply might not change much—giving a false sense of individual accomplishment while letting the collective problem run amok. You might be right to feel excited or relived to have a tad extra protection. But you might also rightfully feel frustrated that it’s a major strategy America is pursuing, instead of focusing more energy on things that would actually help.

For more on why many doctors are skeptical about the need for widespread COVID booster shots, listen to this episode of What Next: TBD.

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