Last week, the CDC recommended booster shots of the Pfizer COVID-19 vaccine for some groups of people. Are you in one of those groups? Do you need a booster dose? Read on for more details.
But first, if you’re age 12 years or older and you aren’t fully vaccinated against COVID-19, then you, yes you, need a COVID shot. The COVID vaccines available in the United States are safe and effective, and they’re the best thing you can do to protect yourself and your loved ones from COVID-19. Run, don’t walk to get a COVID shot if you’re not fully vaccinated.
For those of us who are fully vaccinated, it’s important to understand that not everyone needs a booster dose. A lot of the media coverage has overlooked this. But let’s look at the data.
First, for all the talk of the delta variant, breakthrough infections and waning efficacy, COVID-19 vaccines are still highly effective for most people. A recent CDC publication found that from March 11 – August 15, 2021, while the delta variant was the predominant strain of COVID-19 in the U.S., the Moderna COVID-19 vaccine remained 93% effective against hospitalization for COVID-19 among people with healthy immune systems, the Pfizer vaccine was 88% effective, and the Janssen vaccine was 71% effective. If you are young or middle aged, healthy and not in a high-risk setting, 2 doses of Moderna or Pfizer vaccine or 1 dose of Janssen vaccine still gives you high and long-lasting protection.
Additionally, it’s important to remember that booster doses are not recommended for anyone who received Moderna or Janssen vaccine. This wasn’t an accidental oversight, a victim of bureaucracy or a prioritization of one vaccine or one group over others. Why aren’t people who received Moderna or Janssen vaccine recommended to get a booster dose? Because they don’t need one.
Compare the statistics I quoted above on COVID-19 vaccine effectiveness in spring and summer 2021 to the original vaccine effectiveness estimates in winter 2020/2021: Moderna was originally estimated to be 94% effective, and now estimated to be 93% effective. Pfizer was originally estimated to be 95% effective, and now estimated to be 88% effective. Janssen was originally estimated to be 66% effective and is now estimated to be 71% effective. When you compare those numbers head-to-head, it’s clear that only one vaccine has evidence of waning immunity. In fact, there’s some evidence to suggest that the Janssen vaccine efficacy may improve over time. In other words, if you got Moderna or Janssen vaccine, don’t worry about not being recommended a booster dose and don’t falsify your vaccine history or medical conditions in order to obtain another dose: you don’t need one.
You may be wondering if COVID-19 vaccines are still so effective, then why would the CDC recommend booster doses? The critical answer is that while COVID-19 vaccines are highly effective in healthy, younger or middle aged adults, they are less effective in some other, high-risk groups.
First, there’s evidence that some people with moderate-to-severe immunocompromise don’t develop as strong an immune response to the initial COVID-19 vaccine series. Nearly half of all cases of “breakthrough” COVID-19 have occurred in this group. Therefore, the CDC recommends a third dose of either Moderna or Pfizer vaccine for people in this group. Keep in mind that “immunocompromise” is a broad term that includes a wide range of conditions and treatments. Based on best available evidence, people with mild immunocompromise respond well to COVID-19 vaccines and don’t need a third dose. If you have a condition or take a medication that could mildly suppress your immune system, you don’t need a third dose of COVID-19 and you should not falsify your vaccine history or medical conditions in order to obtain another dose that you don’t need.
Second, as we age our immune system isn’t able to build as robust an immune response as it did when we were younger, and is less able to “remember” immunity to past infections. This phenomenon, known as immunosenescence, explains why, for example, older adults are at higher risk of COVID-19, flu and pneumococcal disease, and why some physicians recommend high-dose flu vaccine for people over 65. Similarly, data collected this spring and summer have shown declines in Pfizer’s COVID-19 vaccine effectiveness in people aged 65 years or older, particularly those living in nursing homes. If you have a loved one age 65 or older and/or living in a nursing home who got the Pfizer COVID-19 vaccine more than 6 months ago, please urge them to get a booster dose.
Third, people with certain underlying medical conditions are at higher risk of COVID-19. There is limited data to suggest that older adults with 1 or more underlying medical conditions might have slight reductions in Pfizer COVID-19 vaccine effectiveness over time. For that reason, the CDC recommends that people age 50-64 with 1 or more underlying medical conditions who got the Pfizer vaccine more than 6 months ago get a booster dose.
Let me clear: while there has been some disagreement among experts about booster doses, nearly all vaccine experts agree that people in the three categories above who received a primary series of Pfizer vaccine should get a third or booster dose. Some of the recommendations (which I’ll discuss in the rest of this post) are controversial, but the 3 recommendations above are not. If you fall into one of these 3 recommended categories and got the Pfizer vaccine for your primary series, please get another dose.
Which brings us to the final two, and most confusing, recommendations made by the CDC. The CDC’s Director Rochelle Walensky issued a recommendation that 2 groups may get booster doses of Pfizer vaccine at least 6 months after a primary series of Pfizer vaccine, but that this decision should be based on their own assessments of their individual risks and benefits: people age 18-49 years with underlying medical conditions, and people age 18-64 years at risk due to occupational or institutional settings. As someone with many friends, family and colleagues who fall into one or both of these categories, I know that a lot of people in these categories are wondering how to assess their own risks, and whether to get a booster.
First, there is no one-size-fits-all answer for everyone in these groups, and experts disagree on their need for booster doses. So, consider the following points my own personal opinions – there’s no scientific consensus on these groups at the moment.
Considerations for people with underlying medical conditions age 18-49 years:
- Number of conditions: there’s some evidence to suggest that people with more than 1 underlying medical condition may be at higher risk of severe COVID-19 than people with only 1 underlying condition. However, there is minimal data comparing the effectiveness and duration of the Pfizer COVID-19 vaccine among people with different underlying medical conditions. If you have multiple underlying medical conditions and you received the Pfizer vaccine as your primary series, you might consider getting a booster dose at least 6 months after your second dose.
- Control of conditions: People with poorly controlled chronic conditions may be at higher risk of severe COVID-19 than people with well-controlled conditions. If you have a single well-controlled condition that isn’t significantly impacting your daily activities, you may want to give the booster a pass for now.
- Age: Remember, booster doses are recommended for people with underlying medical conditions age 50 and up. If you’re in your late 40s with one or more underlying medical conditions, particularly if you fall into another risk factor, you might want to get a booster. On the other hand, if you’re a young adult with a well-controlled condition and without other risk factors, give the booster a pass for now.
- Live or work in high-risk setting: If you have an underlying medical condition and are at occupational or institutional risk, you’re probably at higher risk than someone who only falls into 1 of these categories. You may want to consider a booster, particularly if you have one or more other risk factors.
- Contact with at-risk people: Do you live with or care for someone over 65, an unvaccinated child, someone medically frail or immunocompromised? Consider getting a booster to reduce your risk of spreading COVID-19 to them.
Considerations for people at occupational or institutional risk:
Personal opinion time! I wish the CDC had defined this more strictly. When COVID-19 vaccines were rolled out, eligibility started with a relatively small number of highest-risk occupations, and this group expanded and expanded as vaccine supply increased, until nearly every occupation was included somewhere. That all made sense at the time, but their new booster recommendation links back to that final, nearly all-inclusive definition of occupations. The FDA rejected a vote of Pfizer boosters for everyone, and the CDC’s own Advisory Committee on Immunization Practices also voted down boosters for people under 65 at occupational risk. While it makes logical sense that some occupations are at higher risk, the CDC should have defined those occupations when they made this recommendation. Here are my thoughts on occupations and settings at highest risk:
- Settings where people are in very close contact or live and work together, such as long-term care facilities, jails, prisons and homeless shelters have had many COVID-19 outbreaks. If you live or work in such a setting and received a primary series of the Pfizer vaccine, consider getting a booster dose at least 6 months after your second dose.
- Healthcare workers treating people with COVID-19 are at high risk of exposure; additionally, healthcare workers who work with medically frail or immunocompromised people risk potentially spreading COVID-19 to their high-risk patients. If you’re a healthcare worker who does one of these activities and received a primary series of Pfizer vaccine, consider getting a booster.
- Inability to social distance: If you work in a setting or profession that requires frequent close contact with other people, particularly if that contact is prolonged, and if you got a primary series of the Pfizer vaccine, consider getting a booster. However, if you telecommute or work in a cubicle with minimal contact with other people, a primary series of COVID-19 vaccine is probably all you need unless you fall in another high-risk category.
If you’re not in one of the categories that the CDC recommended for third doses or boosters, then the decision whether to get a booster dose is complex and personal. I hope these tips help you with your decision-making!
As always, stay healthy and keep masking up!
😷 Dr. B
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