Delay 2nd shots, get 1st doses into arms
Responding flexibly to new COVID-19 evidence saved thousands, now we can save thousands more
From Michigan to Massachusetts, COVID-19 cases and hospitalizations are on the rise again. Deaths will soon follow.
We have a way to respond and save lives: vaccinations, which prevent infection and have also shown they are effective in preventing transmission. There will be enough vaccines by sum- mer to vaccinate every American, including children as young as 12. But summer is not here yet. And the recent spoilage of 15 million doses of Johnson & Johnson’s one-dose vaccine means we need 30 million more doses of two-shot vaccines soon, to make up for the loss.
The supply we need is right in front of us. We need only to adopt the sensible, evidence-based policy used in the United Kingdom: Vaccinate as many people as possible with just one dose, by delaying the second dose of Pfizer and Moderna vaccines. Having adopted this strategy, the U.K. has vaccinated 46% of the population and effectively avoided a second surge of the highly contagious B.1.1.7 variant. This is the same strain that is spreading through Michigan, Minnesota and other surging states.
Still time to save lives
The United States does not have far to go. Nearly 121 million Americans have received at least one shot. We need to vaccinate 30 million more people to reach the U.K. level. We are administering nearly 3 million doses a day. If we temporarily delay second doses and continue at that rate, we can get to the U.K. level in about 10 days. That is our best hope of quelling the fourth wave ignited by the B.1.1.7 variant.
Because we did not start this strategy earlier, it is likely too late for Michigan, New York, New Jersey and other Northeastern states. But it might be just in time for the South and California — the next places the more infectious strain will go if historical patterns repeat.
Drug manufacturers chose the threeor four-week interval currently used between doses to rapidly prove efficacy in clinical trials. They did not choose such short intervals based on the optimal way of using the vaccines to quell a pandemic. While a three- or four-week follow-up is safe and effective, there is no evidence it optimizes either individual benefit or population protection.
A single dose of an mRNA vaccine is 80% effective and durable for 12 weeks. Two doses are about 90% effective. In the battle against the surge, a first dose offers eight times more benefit than the incremental protective boost achieved by using that dose for a second shot.
This will reduce inequities
Delivering more first doses is not only more efficient, it is also more equitable. To date, minority and lower-income Americans have received fewer vaccines. This is not a matter of hesitancy but of barriers to access. Doubling firstdose supply would allow states to surge vaccines to vulnerable communities in states facing a new wave of infections.
Conversely, staying on our path would lock in inequity, prioritizing delivery of second doses to the privileged while millions of less fortunate Americans remain completely unprotected and desperate for their first shot.
Some complain that postponing second doses is not “following the science.” But the scientific evidence goes far beyond what was shown in the efficacy trials. Data from the United Kingdom, Israel and now the Centers for Disease
Control and Prevention shows that first doses both prevent infection and reduce transmission. In people with prior infection, experts are beginning to recognize that a second dose could provide even less benefit.
Following the science means updating policies to recognize new evidence rather than stubbornly maintaining the status quo.
Others worry that postponing second doses encourages the development of new variants. This is speculation — not science. This is an insufficient basis for leaving some people entirely unprotected. And published research suggests that expanding first-dose coverage might actually be better not only at protecting the public but also at discouraging variants.
The success of the U.K. strategy over the highly infectious B.1.1.7 variant suggests that the benefits of expanding vaccination coverage outweigh any theoretical risks of inducing new variants.
Still others complain that postponing second doses will prompt hesitancy or confusion. But these claims are scientifically unproven. Many policies have changed during the pandemic, most notably on face masks and safe distancing in schools. Trusted communicators like Dr. Anthony Fauci can lead the charge to explain to the public why the guidance has changed in response to new evidence.
Base policy on facts
Conjecture about public trust is not enough reason to maintain policies that are no longer justified. Policies should respond to the evidence, rather than skewing the evidence over fears about how the public will respond.
We have updated policies before in the COVID-19 pandemic. When we learned that masks reduce the spread of infection, mask guidance was revised. We don’t need a new randomized control trial comparing dosing intervals. That would take time, and meanwhile people would die. Critical care physicians embraced prone positioning for COVID patients despite no evidence from randomized trials. Being flexible and reacting to new evidence saved thousands of lives.
We must get as many Americans as possible at least one dose of the Pfizer and Moderna vaccines. This is how we can save lives and prevent hospitalizations with long-term consequences in this fourth surge.
Govind Persad, JD, Ph.D., is an assistant professor at the University of Denver’s Sturm College of Law, specializing in health law. William F. Parker, MD, MS, is an assistant professor of medicine and assistant director of the MacLean Center for Clinical Medical Ethics at the University of Chicago. Ezekiel J. Emanuel, MD, Ph.D., is co-director of the Healthcare Transformation Institute at the University of Pennsylvania and author of “Which Country has the World’s Best Health Care?”