Ever since the Biden administration announced that it planned to offer coronavirus booster shots to adults who are more than eight months out from their initial vaccination series, many experts have been asking the same question repeatedly: Where are the data?
Now, the New York Times has reported that the US Food and Drug Administration has been asking the very same thing and that it wants the administration to slow down its sprint towards boosters. If there are no data, there can be no assessment of the risks and benefits of providing a 3rd dose. Sound familiar?
The reality is that Israel has decided to boost everyone ages 12 and older based on guesswork. We have time to do better than that.
It appears that the rush to boost here in the United States is based on summaries of the emerging data in Israel. However, the raw data may tell a different story. The data we have from Israel suggest that boosters decreased the rates of infection in adults ages 60 and older during the month of August. But they show that only obliquely and the evidence is highly circumstantial. At least half of the signal is thought to be due to behavioral changes made by people who got a booster. There are other confounding variables that weaken the case for boosters, such as the demographics of those who received boosters compared to those who did not. But assuming that the overall signal is real, we still would need to know how long this protection lasts, and what the net gain is among younger people in comparison to any risks. The reality is that Israel has decided to boost everyone ages 12 and older based on guesswork. We have time to do better than that.
A booster rollout that essentially “flattens the curve” could have important implications in one country, but negligible ones in another.
Because Israel has distinct considerations that may not apply to us, copying their moves may not be so clever. How much you are willing to gamble depends on how much you can afford to lose and how much you need to win. In a geographically small area like Israel with 9.1 million people, hospital capacity is everything. If hospitals in Louisiana are full, doctors can send patients over the border to a hospital in a neighboring state if that becomes absolutely necessary. You can’t exactly do that in Israel. So, a booster rollout that essentially “flattens the curve” could have important implications in one country, but negligible ones in another. The reality is that if boosting merely flattens the curve for a few weeks or a few months, little would have been achieved in areas with enough capacity to treat all Covid-19 patients. But there could be harms, not to mention that a systemic booster campaign is all but sure to widen vaccine disparities both here and overseas.
Given that so far all signals point towards the fact that the two-dose coronavirus mRNA vaccine regimens have the same ability to keep infected patients out of the hospital as the three-dose Pfizer regimen, we need to remind ourselves of why we vaccinated in the first place: not to end infections (though that would be nice), but to eliminate most of the horrifying implications of those infections, such as critical illness and death. We’ve achieved that. The booster campaign in the US has moved the goalposts, without evidence that doing so would be beneficial and safe for everyone. It’s good to see the FDA pushing back.
Up until now...the answer has always been, “We wait for the science.” What will they say in the future?
As before, I maintain that the scientific question of whether or not to boost everyone has not been answered. My belief is not that boosters are dangerous and unnecessary. Rather, it is a matter of fact that we don’t know enough to proceed with a boosters-for-all policy without acknowledging that we’ve decided to guess instead of lean on science. Regardless of what happens, the path that the administration has chosen will end up having negative effects. Either the emerging data will prove them to have been wrong or it will ratify their concerns. If their concerns and approach turn out to be correct, they will have set a dangerous precedent: making policy and taking action before the science supports it. Up until now, when people have asked the administration why it has not acted on a proposed idea—vaccinating kids under age 12, for example—the answer has always been, “We wait for the science.” What will they say in the future?
Where do you stand on boosters? Do you feel that you have enough information to make a good choice? Leave your comments below and join the conversation.
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References and further reading:
Dr. Céline Gounder’s Atlantic piece reminding us what we hoped to achieve with coronavirus vaccinations: https://www.theatlantic.com/ideas/archive/2021/08/americans-are-losing-sight-endgame/619916/
My previous three Inside Medicine pieces on this topic:
Why I’m skeptical of boosters for all. I don’t care what my antibody levels are if they’ll keep me out of the hospital. https://insidemedicine.bulletin.com/891503521746752
I had a chance to get a booster shot. I passed. The science is clear that the data are still too murky. https://insidemedicine.bulletin.com/583009153137416
Your booster questions ASKED. Nobody has the answers, but here’s what we need to find out. https://insidemedicine.bulletin.com/927824401137508
https://www.nytimes.com/2021/09/03/us/coronavirus-booster-shots.html?referringSource=articleShare