(Trends Wide) — To receive a booster dose or not? The U.S. Food and Drug Administration (FDA) and the U.S. Centers for Disease Control and Prevention (CDC) have issued guidance for Some adults may get a third shot of the Pfizer / BioNTech covid-19 vaccine, so it’s time to ask yourself that question.
There are many questions: Who exactly is eligible to receive the booster shot? If you are eligible, should you rush to get vaccinated? What should you take into account in your decision process? And what about those who received the Moderna or Johnson & Johnson vaccines?
To resolve these issues, we spoke with Trends Wide Medical Analyst Dr. Leana Wen. She is an emergency physician and professor of health policy and management at the Milken Institute School of Public Health at George Washington University, and also the author of a new book “Lifelines: A Physician’s Journey in the Fight for Public Health.”
Trends Wide: A lot of people are confused about the latest guidance on reinforcements. Help us break it down. Who can get a booster dose at this time?
Dra. Leana Wen: I think it is important to clarify who is advised to receive a booster versus who can receive it.
In August, the FDA and CDC already announced that people who are moderately or severely immunosuppressed and who received two doses of the Pfizer or Moderna vaccines should receive a third dose of the same vaccine. If you fall into this category of people who received an organ transplant, are on chemotherapy for cancer, or have other immunosuppressive conditions, it is advised that you get a booster dose now. (The FDA and CDC did not provide guidance for immunosuppressed individuals who received the Johnson & Johnson one-dose vaccine.)
What was decided last week is for people who have already received both doses of the Pfizer vaccine, who are at least six months after their second dose, and who are 65 years or older, or 50 years or older and have a underlying medical condition that makes them more likely to have a severe COVID-19 result. Those people are advised to get a third dose of Pfizer, and they should.
Another much larger group may be boosted by Pfizer. This is the group of adults 18 years of age or older, who have underlying diseases or who exercise professions with a high risk of exposure to COVID-19. These people are not necessarily advised to receive the booster, but they can, once they weigh their own risks and benefits in consultation with their doctors.
Trends Wide: Why make this distinction between “should” and “could”?
Wen: The idea is that there is a higher risk group. These are people who are 65 years of age or older, who reside in nursing homes, or who are 50 years or older with underlying medical conditions.
They should receive the third dose and the clearer data indicate that they would benefit. The advisory group essentially said that the benefit-risk calculation is a little less clear for those in the second, broader group. That is why they can get the vaccine and they can choose to do so, but it is not yet advised that they do so.
I think this is an important point. Clearly, those in the highest risk group should receive the third dose if they have already passed the six-month mark since the second vaccination.
Then there are others who should be able to choose for themselves. We are at a point in the pandemic where people are making very different decisions about their own risks. I think it’s reasonable to let people decide on their own level of risk and if they want a boost right now.
Trends Wide: What’s the difference between a third dose of the vaccine and a booster? People use those words interchangeably.
Wen: At the moment these are interchangeable terms. Right now, a person in the United States is considered “fully vaccinated” if they receive two doses of the Pfizer or Moderna vaccines or one dose of the Johnson & Johnson vaccine. A “booster” is the term used for another dose of vaccine for someone who is fully vaccinated. For people who received the Pfizer or Moderna vaccines, which is the majority of the American public, this is a third dose.
Some experts have said that this extra dose for the immunosuppressed should not be considered a “boost” in itself, since they never got the full immune protection of the first two doses to begin with. But that’s a very technical answer. In practice, for those who received the Pfizer or Moderna vaccines, a “booster” and a “third dose” mean the same thing.
Trends Wide: What should people consider when deciding whether to get the booster shot?
Wen: Again, there is a group that really should get the third dose: those the CDC advises to do so. If you are in this group, boosting clearly has benefits in reducing your chance of getting COVID-19 and severe illness.
In the broader group of people who are allowed but not advised to receive the booster dose, the evidence is clear that immunity to mild COVID-19 declines over time. Protection remains strong against serious infection. A third dose appears to increase protection against symptomatic disease.
Some people might look at this data and say, as long as I’m protected against illness serious enough to get me to the hospital, I don’t need a booster dose right now. Other people would say the opposite: they don’t want to get any covid-19 at all. Something that is considered mild could still be very uncomfortable to happen. That person may have to miss work or have problems with childcare.
Even a mild infection can have long-term consequences. For many people, avoiding hospitalization is not the only goal that worries them. If you really want to avoid COVID-19, that could also tip the balance in favor of getting the booster shot once you hit the six-month mark.
Also take into account your own health, as well as risk exposures. The CDC has a list of underlying medical conditions that make a person more likely to have serious consequences as a result of COVID-19. These medical risks are additive. If you have, for example, diabetes, heart disease, kidney disease and emphysema, you are at greater risk of serious consequences than if you only have well-controlled diabetes.
Similarly, if you work primarily at home, you may not have many risk exposures, but if you are a teacher who is surrounded by many unvaccinated and often unmasked children in a cramped classroom, your risk is higher.
Trends Wide: Is there a downside to getting the booster?
Wen: Data from Israel, where there has been an extensive booster program, show that the side effects of the third dose are comparable to those of the second. The most common side effects are local reactions, such as arm pain, and short-term symptoms, such as pain, fatigue, and chills, which resolve within a couple of days.
The only worrisome side effect – although very rare – is myocarditis, an inflammation of the heart muscle, which appears to have the highest incidence among adolescent and young adult males. It is important to note that myocarditis associated with mRNA vaccines is usually mild and resolves without long-term damage, and that COVID-19 itself can cause myocarditis.
Still, especially if you are a young man, but also if you are in the “can” versus “must” category, it is always a good idea to have a discussion with your doctor about the risks versus benefits of the vaccine.
Trends Wide: What if you technically don’t meet the criteria for reinforcement? For example, what if your job doesn’t meet the CDC criteria for a high-risk occupation, but you go to work every day surrounded by unvaccinated and unmasked people?
Wen: To get a booster dose, all you need is a self-certification. That means you make the decision. No doctor’s note or other proof of occupation or medical condition is required. I believe that people should be able to make the decision for themselves, in consultation with their doctor, about what constitutes a high risk. Going to a workplace where you are surrounded by potentially unvaccinated people in a tight, closed environment certainly meets the common sense test of high risk.
Trends Wide: Where should you go to get the reinforcement?
Wen: The US government has created an excellent “vaccine search” website. You can see which pharmacy or local health center has the Pfizer vaccine and make an appointment that way. You can also consult your doctor, as he may have the vaccine available.
Trends Wide: Can people who got the Moderna or Johnson & Johnson vaccines get a booster from Pfizer or a booster from Moderna or J&J?
Wen: Right now, the only people who received the Moderna vaccine who can get a third dose are those who are immunocompromised. Both Moderna and J&J are submitting their booster doses for FDA clearance, and it should be a matter of weeks before we have more information. It is not yet recommended to “mix and match” doses, so if you received the Moderna vaccine, you should wait for the Moderna booster dose rather than the Pfizer booster dose.
I know there is a lot of talk about boosters now, but I want to make one thing very clear: the most important thing from a public health standpoint is still making sure people get their first dose of the vaccine.
Unvaccinated people make up the majority of people who are hospitalized and die from COVID-19. They also make up the majority of transmissions. The administration of boosters to the vaccinated is a plus to increase individual protection, and people should do it if they choose to do so. But we cannot lose sight of the importance of administering the first doses to people who have not yet been vaccinated.