One group that needs boosters can’t get them.

The CDC went big, not smart.

My concerns about universal boosters have been well-documented, both here at Inside Medicine and in the New York Times. To summarize: I’m not anti-booster. I’m pro-booster for people who need boosters and in whom the safety has been established—Pfizer recipients ages 50 and older with certain pre-existing medical conditions, and all recipients over age 65 who are more than 6 months out from the completion of their primary Covid-19 vaccination series.*

Lest you think I’m some cold-hearted servant to data above all else, including at the expense of human suffering for those of us under 50, allow me to speak up for one group of people who arguably should have been among the first permitted to receive Covid-19 vaccine boosters, and for whom there are virtually no relevant data: people living in the same home as profoundly immune-compromised individuals.

These people deserve our attention, especially because they are a group that the Centers for Disease Control and Prevention seems to have forgotten about in its rush to rip the hydrant out of the ground and just let it rain boosters.

For people in this group, the spouse of a bone-marrow transplant recipient on multiple immune-suppressing medications for example, there exists almost no feasible vaccine-related risk that they would not be willing to shoulder in order to temporarily decrease the chances of acquiring a breakthrough infection. To that spouse, the specter of spreading SARS-CoV-2 to their loved one at home, for whom even a 3rd dose might fail to provide adequate protection would be simply unthinkable, if there were something that could be done to prevent it. Whatever risk of myocarditis (or any other adverse event for that matter) a 3rd dose might carry would simply be acceptable to them, even if the rates turn out to be more than 10 times greater than the risk after the 2nd dose.

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When the decision on boosters was announced, it was clear that the CDC had decided to go big, instead of smart. What makes the CDC guidance on boosters so nonsensical is that it excludes people like the one I just described, but includes people with far less to fear from a breakthrough case. The list of pre-existing conditions that allow a person between the ages of 18 and 49 to qualify for a booster under the CDC’s guidelines is inexplicably broad. Many of these conditions carry weak or inconsistent associations with a higher risk for severe Covid-19 even before vaccination, especially among younger adults. And as far as I can determine, virtually none of these conditions have been shown to increase the risk of severe illness from a breakthrough infection, let alone in any statistically or clinically meaningful way. The main exceptions appear to be people with weakened immune systems and organ transplants—for people with those conditions, we already have compelling data that suggest that two doses were never enough to begin with, making 3rd doses essential for them.

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The question remains: is there a downside to boosting young people? The answer to that question can only be determined by reliable data. As I’ve written before, it’s not as easy as just saying “avoiding infection is important.” For example, healthcare workers might actually miss more days of work in the next several months as a result of the adverse effects from boosters than would be avoided by lowering the number of breakthrough infections in that group. If that strains the workforce in the near term, we will have caused harm to patients by not having adequate staffing, precisely when they most need us to be at the hospital.

What about Long Covid? We do not have evidence that Long Covid is common after breakthrough infection. In fact, it appears that Long Covid is significantly less likely after breakthrough infections. When you combine the fact that the vaccines remain impressively effective against even the Delta variant, the chance of a breakthrough infection and Long Covid appears reassuringly low. Nevertheless, everyone has a different risk tolerance. If it turns out that boosters are safe for younger adults (either some or all), a subset will want to proceed, even if the benefit is vanishingly small to them (albeit the equity implications get harder to ignore, the wider the booster net becomes). What bothers me is that the CDC essentially asked young people to do a risk-benefit analysis on boosters, without providing the data needed for such an exercise. We expect complete data from Israel soon. That information will permit these risk-benefit analyses the CDC has encouraged to have actual meaning. (The data shared so far have been incomplete, rendering them uninterpretable). Meanwhile, the agency denied boosters to people for whom even far higher risks than anticipated would be tolerable, if it meant temporarily shielding a gravely ill person in their own home from a possible exposure to Covid-19.

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Recently, I had a patient come to the emergency room with body aches for a few days. There had been a couple of breakthrough cases at her workplace, and she was worried. She was fully vaccinated in April with Pfizer. She was in her 30s. She had one of the risk factors on the CDC’s list. “I’m scared because the CDC just said I have a condition that qualifies me for a booster, but I am not yet eligible because it’s only been 5 months,” she told me. “I heard that the vaccines are losing their power.”

She was breathing normally. Her oxygen levels were perfect. She had no other symptoms. I told her we would test her for Covid-19—not because I was worried about her health but rather so that she could isolate from her unvaccinated school-aged children if she were found to be positive. I also reassured her that even if she did have a breakthrough case, her risk of getting much worse were exceedingly low because, despite what she had heard, the protection she would get from the vaccine remained very high. She had a few more questions, and I was happy to provide answers. All of them were good questions. All of them were prompted by fears that she had understandably internalized over the last few news cycles.

After I had answered her last question, she took a deep breath and just seemed to let it all out. As she exhaled, I could almost see the stress leaving her body. “I feel so much better, doc,” she said. I had boosted her confidence.

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*A caveat. In this column, I do not address whether giving 3rd doses in the United States before others around the world have even had access to a 1st dose is ethical. Here, I’m focused on the science, the direct benefits and possible harms of a 3rd dose. One way of framing this question would be, “If everyone on Earth was already fully vaccinated, would offering everyone a booster be beneficial?”