Why Wait 8 Months?

Posted by on August 17, 2021 7:14 pm
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At this point, COVID-19 booster shots seem all but guaranteed for Americans. Last night, The New York Times and The Wall Street Journal reported that the White House plans to recommend a third dose of COVID-19 vaccine to most Americans who have already gotten two shots from Pfizer or Moderna. The news comes just five days after the FDA authorized third doses for people who have received organ transplants or have certain immune conditions.

White House officials told the Times and the Journal that the upcoming recommendations, which might be announced as early as tomorrow, will apply to people who are at least eight months out from their second dose, and that the third shots likely won’t be available before September. But here’s the thing: Right now, not much is stopping people who have the inclination, time, money, and tolerance of dishonesty from driving to a pharmacy to get another jab. Vanity Fair recently reported that people have snuck a third dose by driving out of state or concealing their identity. Last week, ABC News revealed that an internal CDC memo estimated that at least 1 million Americans have already gotten a third shot—and that was before either announcement.

All of this raises a thorny question for young, healthy Americans who are already vaccinated but concerned about breakthrough COVID-19 cases and the rapid spread of the Delta variant: If three-dose regimens are inevitable, why wait until eight months after your second one—or even a few weeks from now? I put this question to four experts in public health and immunology, and all of them told me that jumping the line probably won’t hurt you. But for a number of reasons, it simply isn’t worth it for many people.

Perhaps the most straightforward argument against getting an illicit extra shot is that the public doesn’t have enough data yet to be certain that it’ll make a difference, especially for people who have already had a two-dose mRNA regimen. Immunologists do broadly believe that boosting could offer some added protection in the short term, Ali Ellebedy, an immunologist at Washington University in St. Louis, told me. That’s not nothing, especially during a significant surge in the pandemic. But our outlook is limited by the fact that there’s virtually no data so far on whether non-immunocompromised people stand to gain any long-term protection. Pfizer shared some preliminary data from their clinical trials of booster shots in a recent earnings call, but they only show levels of antibodies in the blood—an imperfect proxy for how protected people actually are from sickness—and only track participants for a month after their third dose. Ellebedy would like to see six months’ worth of clinical data in order to make a judgment about whether the third shot truly changes things.

If those data become available before you’re eligible, you probably still won’t want to finagle your way into a dose before your turn, because skipping the line conceivably could hurt your protection in at least one way. Marion Pepper, an immunologist at the University of Washington, told me that overstimulating the immune system can make your body less adept at fighting off certain infections; scientists haven’t yet figured out whether that’s true for COVID-19, but Pepper sees it all the time in her work on malaria. Your immune system “needs some time and space to calm down in between seeing one infection and the next one” so that it can hone its pathogen-detection skills, Pepper said. Hitting it with another vaccine before it’s ready might not make it any better at fighting the coronavirus. (For immunocompromised people, whose bodies likely didn’t produce enough of an inflammatory response to get sufficient protection from their first two shots, this isn’t as much of a concern. “​​The priority there is to let them get their immunity at a good level,” Ellebedy said.)

Why the White House is reportedly recommending an eight-month timeline is not yet clear. “I was concerned to see the statements last night coming from the White House” rather than career scientists at the FDA or the CDC, Jason Schwartz, of the Yale School of Public Health, told me. Decisions about dosing, timing, and the like are “best left to the scientific officials who have the right skills and tools to think about the evidence,” he said. (White House Press Secretary Jen Psaki said during a press briefing today that the administration will “discuss next steps as it relates to boosters” tomorrow. A White House spokesperson declined to comment further to The Atlantic.)

Yesterday’s reports were met with fierce pushback from many public-health experts, who objected to a policy of prioritizing boosters for healthy Americans over first-round shots and more basic interventions even before the news broke. Last week, two epidemiologists wrote in The Washington Post that third shots alone simply don’t have the power to stop the spread of the highly contagious Delta variant, which is now the main driver of coronavirus cases in the United States and worldwide. They could possibly make breakthrough infections less likely, and therefore vaccinated people less likely to spread the virus, but neither Pfizer nor Moderna has proved that publicly. The same number of shots would do much more to tame the pandemic if they were distributed as first and second doses around the world, the Post article showed.

That’s not to say that you forgoing a dose will immediately teleport it to a vulnerable person in one of the dozens of countries worldwide where less than 5 percent of the population is fully vaccinated. “Vaccines that are already available and being manufactured here in the United States are not going to be rerouted to global markets right now,” Schwartz said. Even so, healthy, young Americans clamoring for bonus shots is far from the most pandemic-thwarting use of resources. Esther Choo, a professor of emergency medicine at Oregon Health and Science University, recommended that fully vaccinated, non-immunocompromised people who are concerned about their own safety spend their energy advocating for vaccine equity worldwide, which will ultimately protect them too. Faking your way to a third dose can skew data on vaccine efficacy, making it harder for epidemiologists to fight the coronavirus in the long run, Choo told me.

If and when the FDA and the CDC do green-light third shots for all, choosing to get one will be a nuanced and personal decision; hopefully, by then, the public will have access to more data to guide them. (And hopefully the agencies will have offered more advice to Americans who got the one-dose Johnson & Johnson vaccine, which may be slightly less effective at preventing infection with the Delta variant than the mRNA options.) Schwartz believes that if people are “following the rules or following guidelines or following the recommendations that had been developed by responsible health authorities,” they “can in good conscience” accept a third dose that’s offered to them.

Pepper said that, given her age and health status and all the information available to her right now, she wouldn’t take a third shot unless her hospital recommended it. But, she said, people over the age of 70 or 75 might want to consider it post-authorization, given evidence that antibody counts can start to wane among some older adults after a few months. Choo also told me that, for now, she wouldn’t take another vaccine dose, though she doesn’t begrudge people who want one when it’s offered. If the people around you refuse to mask up, or your Facebook feed is covered in COVID-19 conspiracy theories, “those things are so disempowering,” she said. Getting a third dose might help people feel a little more hope.

Ellebedy, like Schwartz, said he would take a shot that’s offered to him, but it’s not really the outcome he wants. He has three kids at home between the ages of 5 and 12—in the group that’s still waiting on a vaccine authorization—and all of them started school today in Missouri, where only 43 percent of people are fully vaccinated. “I will personally take it. I will go. I’ll stand in the line,” he said. But “I would definitely prefer if one of my kids get it before I get a third shot.”

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