Q&A: Do I need a booster shot as delta surges?
Clamor for an extra dose — or booster shot — of coronavirus vaccine is rising, as the highly contagious delta variant causes even vaccinated people to get occasional infections. In San Francisco, people who had received the singleshot Johnson & Johnson vaccine lined up Wednesday at San Francisco General Hospital to get a dose of mRNA vaccine, in what appears to be a firstofitskind program in the country.
No official federal guidance has been issued on boosters. People who are older, have compromised immune systems, or got the J&J vaccine are particularly anxious for more information. But boosters are also controversial, because for every extra shot that an American gets, the glob
al supply of the lifesaving vaccines shrinks. And 42% of Americans have not gotten even one dose, leading some experts to believe the priority should be to get them vaccinated first.
Here is what we know about the latest developments:
What is San Francisco doing?
San Francisco is allowing people who got the Johnson & Johnson vaccine to seek an mRNA shot of Pfizer or Moderna at cityrun clinics. It is believed to be the first U.S. jurisdiction to permit a “supplemental shot,” as city officials are calling it. San Francisco health officials emphasize they are not recommending that everyone who got the J&J get an mRNA shot, and that this option should be limited to J&J recipients who have had a discussion with their doctor.
What is the U.S. doing?
The federal government has not recommended additional shots for people who are already vaccinated. Dr. Anthony Fauci has indicated in recent days this may change soon for some vulnerable Americans, saying a recommendation is “likely” coming for people who are immunocompromised. Officials have not specified whether this would be for people who got Pfizer or Moderna, or J&J. Pfizer is expected to apply for FDA authorization for a third dose this month. If the FDA grants full approval of the vaccine, which it’s expected to do in September, doctors could prescribe a third dose to patients who they think need it.
Are any other Bay Area counties or providers offering additional shots for J&J recipients? Not right now, because the CDC and FDA do not recommend it. But some counties are watching how San Francisco’s policy plays out, and acknowledge that the decision to get an additional shot is best left up to individual providers and their patients. Additional shots at this point are considered offlabel.
Solano County said it is monitoring what San Francisco is doing and, if the state deems it appropriate, may implement a similar policy. San Mateo County said some providers may be doing it on a casebycase basis: “We know there are vaccinating providers who may use their clinical judgment to consider offlabel uses for patients in casebycase situations and we defer to their judgment in such cases.”
What is the rest of the world doing?
Israel last week became the first country to authorize booster shots — a third dose of Pfizer — to people over 60. Germany followed suit this week, saying that starting in September it will allow a Pfizer booster for some highrisk people, such as those who are older, live in nursing homes, or have compromised immune systems. Germany will also offer boosters to people vaccinated with the AstraZeneca or J&J vaccine, which studies have shown are not as highly protective as the mRNA vaccines.
The World Health Organization, though, says booster shots should be halted until the end of September so at least 10% of the population in every country can get vaccinated.
“Even while hundreds of millions of people are still waiting for their first dose, some rich countries are moving towards booster doses,” WHO directorgeneral Dr. Tedros Adhanom Ghebreyesus said Wednesday.
Are boosters safe? Yes. There’s not yet much data to quantify the exact immune response benefit of giving additional shots to vaccinated people, since the clinical trials tested for a twodose regimen (Pfizer and Moderna) or onedose regimen ( J&J). But receiving an additional dose should not harm you, experts say. This is based on ample evidence from previous widely used vaccines, and from what is known about how the immune system responds to vaccines.
Are boosters needed?
There is growing consensus that boosters will likely help the most vulnerable who have been vaccinated — those with compromised immune systems — build extra protection against COVID, especially now that the highly contagious delta variant is spreading so quickly.
But it’s unclear exactly how beneficial they would be, and whether everyone will need them.
Studies show that antibody levels, which are one but not the only marker of immune response, wane after six months postvaccination; this is to be expected, and doesn’t necessarily mean someone is no longer protected after six months. And studies on memory T cells and B cells — markers of longerterm immune response — suggest the vaccines work well in the long run.
Who should be considered for a booster first?
Experts say it’s reasonable for those with the most weakened immune systems — such as solid organ transplant recipients, people with leukemia or on dialysis, and people undergoing chemotherapy — to get boosters first. Immunocompromised people may not have an effective enough response to vaccines because disease or medication has weakened their immune system. However, it’s not clear that this group would respond to a third shot any better than the first two, said UC Berkeley infectious disease expert Dr. John Swartzberg.
“The immune compromised group, which is such a logical group, we don’t have robust data that they will respond to a third jab any better than the first two,” he said. “It may be holding out a false hope to people in that group.”
Some also think it’s reasonable for J&J recipients to consider boosters, too, since studies show this singledose regimen is not as highly protective as the Pfizer and Moderna vaccines. This is what Germany will do for those who got the J&J and AstraZeneca shots.
It is also reasonable that the earliest recipients of the vaccine — those who got it at the start of the rollout, in December or January — start getting boosters to learn more about the benefits of additional shots. Those would be people who got Pfizer or Moderna, since those two vaccines were authorized in December and J&J was not authorized until the last week of February.
“Those who got the original shots or two shots back in January and December last year, or they’re immune compromised — those would be the subgroups to target now for a booster and learn from it,” said Stephen Shortell of UC Berkeley’s School of Public Health. “Give it to them, see what the reaction is, follow them over time.”
Some experts note that age in and of itself may not be the best measure of who needs a booster. A healthy 65yearold, for instance, may not need an additional shot, while a 25yearold with multiple comorbidities might.
Is it ethical to give boosters?
Some experts say boosters are morally questionable in the context of global public health, even though they may benefit some individuals. This is especially true because all the vaccines are very effective at preventing the most severe disease, hospitalizations and death — so those who’ve been vaccinated are already mostly protected against the worst outcomes, while those who are unvaccinated remain extremely vulnerable. The pandemic may only end once everyone or almost everyone, not just people in some regions or countries, are vaccinated.
“A good argument could be made for selective people in our society to get a booster,” Swartzberg said. “The 2.7% of the population that is immune compromised, you can make an argument for that group. You could make an argument for health care workers and other people at very high risk. But you can make an argument against these, too. One argument against it: People aren’t dying who are vaccinated ... Then the global question is how can you be giving a third jab here when you’ve got the bulk of the world not even having access to one? And it’s in our longterm interest to vaccinate the world.”