Boost Your Vaccine Confidence
Apparently I’m now eligible for a booster shot, but I’m not rushing out to get one.
As a physician who gleefully got my Pfizer shots over 6 months ago, this weekend I could have marched into CVS and dosed up. I could have stockpiled COVID antibodies and my favorite “I’m-in-a-pinch” hair dye (buy one, get one free this week!).
But I didn’t.
If I thought—or ideally if I knew—that a third dose would protect me or the people around me from COVID in some meaningful way of course I’d take it.
But the data simply isn’t there to justify another shot for someone like me. For the vast majority of people, the vaccines continue to be highly effective against death and severe disease. When and if we have compelling evidence that the benefits of boosting healthy people with normal immune systems outweigh the potential harms, I will gladly roll up my sleeve. (Again, right now we simply don't.)
Last week the CDC decided that the following folks should get a third dose of the Pfizer vaccine at least 6 months after their primary Pfizer series:
people over age 65 years
residents of long-term care facilities
people aged 50–64 years with underlying medical conditions.
I wholeheartedly agree. The evidence is clear that these groups are at highest risk for poor outcomes from a breakthrough infection. (Note that still the vast majority of people getting severely ill from COVID are people who are unvaccinated or non-immune adults.)
The CDC also decided that the following groups of people “may” get a third dose of the Pfizer vaccine after their primary Pfizer series:
people aged 18–49 years with underlying medical conditions based on their individual benefits and risks, and
people aged 18-64 years who are at increased risk for COVID-19 exposure and transmission because of occupational or institutional setting, based on their individual benefits and risks.
(The CDC already allowed third shots for immunocompromised people who got Pfizer or Moderna shots but has not yet made recommendations for all recipients of the Moderna and J & J vaccines.)
Here is where I and many other public health scientists, virologists, and medical experts are having trouble. The latter two categories of people eligible for booster shots are vague and not clearly rooted in scientific evidence. An excellent summary of my thoughts about the booster rollout is in this opinion piece by Drs. Megan Ranney and Jeremy Samuel Faust. Just yesterday, the editorial board of the New York Times also chimed in, issuing a scalding rebuke of the booster rollout. I agree with many of their points. I strongly encourage you to read both articles as background.
In short, the CDC’s guidance leaves a lot of room for interpretation.
On the one hand, that seems good, right? Talk to your doctor to make a decision. Indeed there are many people—like my 35-year-old patient with obesity and an inherited clotting disorder—who likely will benefit from a third dose but don’t meet the strict criteria listed above. And so she and I will talk about it. Discussions with patients about balancing risk and reward (not merely about COVID) is not only my job; they are some of the most gratifying conversations to have!
But in reality, what’s happening is that the conversation about boosters is making already-vaccinated people generally more anxious and unvaccinated people even more reluctant to get the shots. My anecdotal evidence?
Friday and today at my office, the phones were a-ringing after the CDC’s guidance was announced. I spoke with many patients, two of whom had questions that are representative of the challenges of our time: decoupling politics and science, the dearth of transparent communications on public health and medical information, and the difficulty of managing people’s expectations after 18-plus months of uncertainty and fear.
One is a healthy patient of mine in her early 50s who had a bad bout of the flu in 2018. She was sick enough to miss a week of work and felt pretty awful (cough, fever, body aches) despite having had the flu shot. She called me on Friday to ask me if her 2018 dust-up with the flu qualified her for a third Pfizer dose. I told her that it didn’t—and that getting the flu doesn’t represent an underlying medical condition; it was simply bad luck.
Naturally anxious about getting sick again, she then asked me: “But wouldn’t a third shot help me be less sick if I got COVID?” I gave her my honest answer: I don’t know. In fact, no one knows. “Wouldn’t I protect my unvaccinated son by getting boosted?” Again I told her: I don’t know. Is it possible that if she got a breakthrough infection, she’d feel sick for 4 days instead of 5 after having had a booster shot? Sure. Is it possible that if she were to be exposed to COVID, got infected but exhibited no symptoms, that a third dose of the vaccine would further limit the viral load in her nose such that she would be less likely to transmit the virus to her child? Sure. All of these things are possible. But so is the possibility that a third dose could do her more harm than good. We just don’t know.
A book I’d love to write some day would be called Just Because We Can, Doesn’t Mean We Should. In other words, there's a reason doctors don't order full-body CT scans on every patient or prescribe Lipitor for every patient with high cholesterol. I don’t react to the new diagnosis of breast cancer in a 40-year-old by ordering mammograms on all of my 39-year-olds. There’s a method to practicing medicine. Doctors use evidence, context, and clinical judgment—not “what if” thinking—to make complex decisions.
In the scenario of a healthy already-vaccinated patient, my job isn’t to green-light a booster shot that she probably could access at the local pharmacy with ease. It’s to manage her (appropriate) fear of getting sick—and her expectations of life with an endemic virus. After all, COVID isn’t going away. We cannot eliminate risk; we can only mitigate it. The currently available vaccines continue to work well against coronavirus. They also clearly reduce transmission to other people.
In other words, once you’ve been vaccinated, you’ve taken the best step possible toward protecting yourself and other people.
Another patient I spoke to Friday is an athletic 57-year woman who has repeatedly declined COVID vaccination. She is smart, educated, and reasonable. She is also highly suspicious of Big Pharma and the Federal Government. She’s one of my very favorite patients; we simply disagree on the risk/benefit ratio of vaccination for her. Nonetheless, I have been gently chipping away at her vaccine hesitancy since springtime.
Just last month I had a window! We met in person so I could medically clear her for an upcoming orthopedic surgery. Delta was surging, and I explained to her that eventually we’ll all be exposed to coronavirus—and that I’d rather her get immunity through safe vaccination than through a battle with COVID itself. She paused. She told me that was the first time anyone had put it that plainly and that she’d give it some serious thought.
I remained optimistic until we spoke again on Friday, hours after the FDA/ACIP/CDC flip-flop. She chuckled when I asked her if she’d decided to get vaccinated. “I hate to burst your bubble, Dr. McBride, but why would I trust a vaccine that Pfizer is pushing so hard? And now I‘m supposed to get three doses of it and still have to mask indoors?” I explained again that the primary vaccine series has been proven safe, dramatically drops the risk of death and hospitalization, and reduces the risk of transmission to others.
“I’ll pass for now.”
I empathized. “I feel the same way about my booster shot.”
“Really??” she asked, surprised.
I lept at the chance to explain myself and the opportunity to further instill trust. After all, my job isn’t to parrot headlines or blindly endorse boosters-or-bust rhetoric without thinking through the issues myself. I told her that I’m well aware that I could still get COVID despite my two Pfizer shots. This is our unpleasant reality—and is the reason I got my two doses last winter. I’m also aware that my blood antibody levels probably are lower now than they were back in February—but that this is entirely normal and is not itself synonymous with waning immunity. In fact, if antibody levels didn’t drop after every infection or vaccination, our blood would become a dangerously thick SLUDGE of antibodies. Instead, our immune systems smartly create memory cells able to make fresh batches of antibodies when we’re inevitably exposed to coronavirus—plus T cells to prevent severe illness. I’m lucky to be carrying around an arsenal of vaccine-induced weapons to fight the real thing when I need it.
In other words, I’m as protected as I possibly can be from COVID right now, and because of the vaccines (and because I’m lucky that my household and the vast majority of my patients are fully vaccinated and because I symptom-screen patients before I see them), I don’t spend any time worrying about getting severely ill from COVID. As I explained to my patient, the beauty of vaccination is not having the stress of gambling with your life.
She listened intently. And at this point of our (long) conversation, my patient was back on my side of the fence. “I’ll reconsider the vaccine, Dr. McBride.”
So what should you do if you’ve had the Moderna series?
We’re still awaiting guidance, and I suspect this will come in the next few weeks. In the meantime, I am recommending to many of my Moderna recipients who are at highest risk for severe outcomes from a breakthrough infection (over 65 years old, immunocompromised, organ transplant patients, nursing home residents) get a third dose of either Pfizer or Moderna.
We have decent enough data in my opinion to show that mixing and matching vaccines is effective and actually may confer an immunological advantage. It also makes intuitive sense that the mRNA shots could be used interchangeably. That said, formal guidance has not been given, and the effectiveness of the primary Moderna series remains excellent against severe COVID. In other words, most Moderna recipients should feel comfortable waiting for official guidance but also should talk to their physicians about getting a third dose if high risk.
What about J & J recipients?
The evidence seems clear that 1) the single shot continues to provide excellent protection—albeit less than the Pfizer and Moderna shots—against severe COVID and 2) two doses is better. Official guidelines have not yet been made. In the meantime, I’m recommending a single mRNA shot to my highest risk J & J recipients—for example my elderly patient who lives with an immunocompromised adult daughter.
Tara Parker-Pope from the New York Times had a great booster shot Q & A last week. (I agree with pretty much all of it except the notion that highest-risk patients—as outlined by the CDC’s with the first three categories up top—who received Moderna or J & J should wait for official word to get a third shot.)
The big-picture problem is this: while we can vaccinate against COVID, there's no inoculation against pandemic anxiety. And until we have evidence that our own health is optimized by getting a vaccine booster, we must trust these extraordinary vaccines and our own immune systems to keep us safe enough that we can focus on other threats to our health and well-being.
Many people seem to think that we can boost our way out of the pandemic—that we can somehow drive the risk down to zero (or somewhere close) and can fully insulate ourselves from COVID-19. We can’t. The way out of the pandemic is by vaccinating people who are not yet immune, accepting the unpleasant reality that COVID is here to stay, balancing the benefits and harms of pandemic restrictions themselves, and managing our expectations about risk.
I will see you next week. Until then, be well.