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Why A Simple Question — Who Should Get A Booster Shot? — Became So Messy

cwick (Chadwick Matlin, deputy editor at FiveThirtyEight): Betsy, Maggie, hello! I’ve asked you to join me to talk about COVID-19 booster shots in the U.S. and what a confusing mess it is to know whether we should be giving boosters to all already-vaccinated Americans, or to just some.

Let’s start by declaring our biases: Have you been boosted???

betsy (Betsy Ladyzhets, FiveThirtyEight contributor and author of COVID-19 Data Dispatch): I have not. I became eligible in NYC (where I live) earlier this week, and I’m kinda going back and forth on whether it’s worthwhile for me.

maggie (Maggie Koerth, senior science writer for FiveThirtyEight): I haven’t, either. I’m technically eligible because I have depression, and mood disorders are included in the “complicating medical conditions” criteria, but I’m also not sure if it’s for me.

cwick: I also live in NYC and had been waiting for it to become approved for me. But since NYC changed the rules for who’s eligible (which we’ll get into in a minute), I made an appointment and went to get my booster shot today … only to realize I scheduled it for next Wednesday.

But as I was waiting in line, I wondered, Why am I getting this thing again? Yes, I have a 2-year-old whom I should try and protect, and a (boosted) wife who is a teacher interacting with lots of kids. But I am not sure if getting boosted would really help cut the severity of COVID-19 down if I got it.

What’s the latest on the science of what boosters do and don’t do?

maggie: Well, I think an important place to start is by clarifying what your original vaccination does and doesn’t do. I feel like, anecdotally, a lot of people have the impression that the original vaccinations are failing at a high rate, and that’s just not true.

betsy: Right, the vaccines are still doing a very good job of protecting people against severe disease and death, which was the original goal. Breakthrough cases, when they happen, tend to be milder and shorter because vaccinated peoples’ immune systems are primed to respond to the virus.

maggie: As far as anyone can tell, there’s been very little change in vaccine effectiveness for hospitalization and death. There’s been a reduction in effectiveness of whether you get an infection at all … but even that is still reasonably high. In a recently published study of frontline workers in the U.S., effectiveness is still holding around 66 percent for the mRNA vaccines post-delta variant. But that includes asymptomatic infections. Some studies found higher rates of effectiveness against any infection, some lower. This is really middle-of-the-pack.

betsy: Seniors and people with certain health conditions may be exceptions to this, though. Especially for those seniors who got vaccinated very early on (like in January 2021), their immune systems may have less capacity now to respond to a COVID infection than they did closer to their vaccinations.

maggie: I was just looking at some charts today from the CDC that show that the surge in cases and hospitalizations — which is serious stuff — is being driven by unvaccinated people. Not breakthroughs.

But, like Betsy says, people over the age of 65 and the immune compromised are a different story. Currently, the CDC recommends a six-month booster for people who are 65 and older, people who are between 50 and 65 and also have underlying medical conditions and people 18 and over who live in long-term care. Anyone who got the J&J shot should get a booster after two months. The agency has also approved vaccination — they made a distinction earlier this month between who SHOULD get it and who CAN — for 18- to 49-year-olds with underlying conditions and any adult who works in or lives in a high-risk setting, like a nursing home.

Illustration of COVID-19

Related: The Science You Need To Make Your COVID-19 Decisions Read more. »

betsy: Yesterday, I was reading about a nursing home outbreak that happened in Connecticut over the past month and a half — almost all of the residents and staff were vaccinated, but they had a big outbreak of breakthrough cases and eight residents died. The facility had planned to offer all residents and staff boosters, but it hadn’t happened yet when this outbreak started.

maggie: Yeah, stuff like that does make boosters important. And the list of people who are eligible could soon expand even more. On Wednesday, NPR reported that the FDA is likely to approve emergency use authorization for any person 18 and over. 

cwick: The vaccine itself is, of course, not just about ourselves, but about protecting others. Is there some reason to think a booster could help protect the unvaccinated, and thus there’s a public health benefit, even for younger people?

betsy: I think that question is more complicated. Data from Israel, which has had booster availability for all adults for a while now, suggests that after a bunch of people got booster shots, overall case numbers (including in unvaccinated people) went down — and Israeli scientists say they essentially boosted their way out of a surge. But I have seen some skepticism over whether the boosters really did that, or whether it was more that people got boosted around the same time as the virus was falling into a natural pattern of decreasing cases.

maggie: I know there was one study out of Israel that has been presented as evidence that boosters increase protection significantly, but the people who were boosted just weren’t followed for very long at all — only about seven days post-booster, on average.

betsy: Right. I think this also becomes a question about the underlying biology of the vaccines — we know that both the primary shots and booster shots cause patients to produce a ton more antibodies against COVID-19. That seems to correspond with someone’s protection from COVID infection and transmission, but scientists don’t have a good handle on exactly how well it corresponds. (Or how well it correlates, to use a more precise term.)

maggie: I struggle with all of this, honestly. There’s not a ton of evidence that boosters are necessary for most people. … I mean, this is why scientists are still genuinely debating the issue. But I also feel very weird being that contrarian voice that’s like, “Ehhhh, do you really need this?” when what we’re talking about is about improving protection and whether the trade-offs for slightly better protection are worthwhile. Shouldn’t more be better, you know?

betsy: Yeah, I feel the same way.

maggie: I don’t want to be the devil’s advocate for the virus, I guess. The COVID-19 lobby is not paying me enough for that.

betsy: There’s also the question of what we’re trying to protect against. Is it severe cases and hospitalizations, or just cases overall? Maybe a vaccinated person who works in a public school, for example, is protected perfectly fine against a severe COVID case, but if they have a mild breakthrough case, then they could cause their classroom to be shut down for a week. So it seems worthwhile to give that person a booster and decrease the chances of a mild breakthrough case. But then it’s like … are we going to give everyone boosters forever to stave off these mild breakthrough cases?

maggie: That’s very much where I am sitting internally, Betsy.

cwick: All of this gets into whether there are any downsides for getting the booster when you don’t “need” it, and whether the FDA should be in the business of explicitly saying yes or no. There’s a difference between approving the booster for only some people and banning the booster for some people.

Maggie, you’ve reported on how the CDC makes its decisions, and how sometimes its caution can get in its way. Is that happening here?

maggie: Chad, I’m not really sure. I’ve looked at lots of documents from the internal CDC debates around this, and at papers where FDA experts have talked about the pluses and potential minuses of boosters. There’s certainly a lot of thought and research going into trying to figure out what the cost-benefit balance is … which I think there SHOULD be. And I don’t think we know yet whether this is good caution or bad caution. It’s easy to look at this and wonder, OK, is this going to turn out to be analogous to everybody second- and triple-guessing the use of masks early in the pandemic … or is this going to be analogous to medical science realizing that blanket screenings for prostate cancer were causing more harm than good.

I think it IS a really great example of why the CDC can get bogged down by its own decision-making process, though. Because these aren’t easy decisions to make.

betsy: Listening to the advisory-committee meetings, I noticed that there seems to be this tension between the scientific experts who want to make robust evidence-based decisions — and the sense that, here in the U.S., our overall pandemic strategy is basically “vaccinate our way out of the pandemic.” If we had better masking, distancing, contact tracing, ventilation, rapid tests and everything else, we would not need boosters to stop people’s mild cases. But we’re not doing a great job at any of those other things, so … we kinda need boosters.

maggie: Very much agree with that, Betsy.

betsy: The CDC and FDA committees whose job it is to make very scientific decisions are influencing things that they’re probably not used to influencing, I think.

maggie: I think it factors into a political angle. The people in charge need to be seen to be doing SOMETHING. And it’s a lot more politically expedient to get a booster approved for everyone (or just decide your state is going to make it available to everyone) than it is to get cheap, rapid testing rolled out.

betsy: Or to do good contact tracing, or to require people to wear masks in public spaces, or to limit event sizes, or …

maggie: Even if the testing would make a bigger difference than the booster.

cwick: For sure. You can see some of the politics in how President Biden moved faster than the CDC on boosters.

betsy: Yes, definitely.

cwick: And you can see more of that political confusion in how some states and municipalities have moved to go beyond the federal authorities and open up boosters to all. That’s how Betsy and I could get a booster right now in New York City, and several states — not all of them controlled by Democrats — have now opened boosters to all, as long as the last round was six months prior to mRNA vaccines (or two months if you got the Johnson & Johnson shot).

maggie: I think it also gets into the personal need to feel in control of something. This is just my speculation, but if you look around my state right now, Minnesota is currently the nation’s COVID hotspot. And there’s not a clear reason why that is. The vaccination rate is roughly the national average — so, not low. The remaining people who aren’t vaccinated are either the tough population to reach, or kids. And feeling like you have no hand on the lever is a lot to deal with. By getting a booster, you at least feel like you’ve made a productive contribution to a better future.

betsy: I agree with that. And it’s nicer to post a “booster shot” selfie than a, like, “I wore my mask at the grocery store” selfie.

maggie: I’m going to start posting selfies every time I buy a $25 rapid test.

cwick: 👏 Normalize 👏 mask 👏 selfies 👏 at 👏 the 👏 grocery 👏 store 👏

betsy: I do take pictures of my antigen test results sometimes, but I never share them! Gotta change that.

NYC is one place that I think has particularly leaned into the “vaccinate out of the pandemic” strategy. When the initial delta wave hit, city leaders didn’t put in a new mask mandate — instead, New York became the first major U.S. city to require vaccinations for restaurants, gyms and other indoor spaces. So I wasn’t surprised that it’s also one of the places doing this “boosters for everyone” move.

cwick: But wouldn’t Democrats be going nuts if this were happening in the Trump administration? You can hear the press conferences now: “An FDA and CDC that’s dragging its feet on combating COVID means we have to take matters into our own hands.”

betsy: It feels a bit more complicated than that to me, honestly, because the Biden White House was pressuring the FDA and CDC in this direction to begin with.

cwick: Politics has no room for “complicated,” Betsy!

maggie: Betsy, Chad hates it when my thesis is “It’s complicated.”

betsy: Alas, that’s the thesis of basically every COVID story …

maggie: COVID finally allowed me to win that fight.

cwick: It’s been a challenging time.

maggie: I think part of the problem here is that the downsides to universal boosters are not perfectly easy to articulate and grok. It’s “do the thing we know helps but MORE” versus “Wellll, but are we undermining public trust in the vaccines and are we preventing access to the vaccines by countries that haven’t gotten their first shots, and how many cases of myocarditis are worth it for a temporary increase in effectiveness against asymptomatic infection?”

betsy: I agree with you, the communication challenge does not help. … I keep thinking about that Kaiser Family Foundation poll saying 4 in 10 vaccinated adults don’t know if they’re eligible for a booster.

maggie: Hell, I’ve been confused about that.

cwick: It sounds like all three of us are in that 40 percent! And maybe MORE people shouldn’t know if they need it.

betsy: I am also kinda concerned about the way that this booster-shot rollout in the U.S. could once again exclude people who genuinely do need the shots — like seniors who don’t speak English, or don’t have an easy way of following the news

maggie: Maybe the biggest issue here is that sometimes there is not an absolute objective answer that applies universally … and making policy off of that reality is a real pain in the ass. Evidence-based policy expects an objective absolute answer to build off of. Science doesn’t always give you that.

betsy: Yup. And particularly here in the U.S., we still have gaps in our data on breakthrough cases — data that ideally would tell us who most needs the booster shots.

maggie: Right! That was such a smart and important point you made in your article on that. Part of why we don’t know is we haven’t done the work to friggin’ look. Because that work was not as politically expedient as “vaccinate our way out of the pandemic.”

betsy: Thank you! In an ideal world, scientists would have, like, two to three years to gather data on that exact question, and then all the FDA and CDC experts could make a real, evidence-based decision. But instead, the weather is getting colder and cases are going up again, and the Biden administration is freaking out about their bad approval ratings. … We don’t have that time.

cwick: I am searching for a nice tidy way to end this chat, but it seems too — yes — complicated to wrap up neatly. It’s hard to do service-y journalism for folks about whether they need a booster when there’s so little clear, empirical evidence about whether they need a booster.

maggie: Yeah. My service-journalism advice here is, “Scream at your public representatives with a pitchfork in hand.”

betsy: For me, I think I will likely get one. Even though I don’t agree with my city’s “vaccinate out of the pandemic” strategy, I feel I should contribute to what the health leaders have decided they’re gonna do. And then I will do some screaming about vaccine access.


How COVID-19 vaccines work

maggie: I will say, if you’re under 65 and you’re not immune compromised, it almost certainly matters more to get your kiddos vaxxed the first time than to get yourself a booster. That’s my parent-centric takeaway from all this reading.

That, and it is extremely important to get first vaccinations rolled out in countries that haven’t had much access to the vaccines. And that is also probably a LOT more important to reducing the severity of this disease globally than whether I — a rich, white American — get a booster. 

betsy: There are currently six times more boosters being given in the U.S., Europe and other wealthy nations than primary doses being given in low-income countries!

cwick: Right, the other context we can’t escape here is the “first-world problems” nature of all this. While we struggle to figure out what to do with booster doses, plenty of countries struggle to find first and second doses for their citizens. Should that factor into individuals’ ethical decision-making here?

betsy: I don’t think it should factor into individual decision-making, because unlike in the early days of the vaccine rollout, the U.S. has plenty of doses to give everyone boosters — if you don’t get a booster, that shot does not automatically go to someone who needs it more. The U.S. choice to hoard doses was made already. But there are other options for people who feel strongly about this, like contacting your representatives.

maggie: This is where the pitchforks come in.

Maggie Koerth is a senior science writer for FiveThirtyEight.

Betsy Ladyzhets is a freelance science, health and data journalist currently focused on tracking the pandemic.

Chadwick Matlin is a deputy editor at FiveThirtyEight.

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