The COVID Booster

Updated June 20, 2022

As of June 18, 2022, the COVID vaccine is available to anyone 6 months old and older, in the United States for protection against severe COVID disease and death. Many have not taken advantage of this, either by not getting fully vaccinated or not getting vaccinated at all. While 59% of adults have been fully vaccinated and an additional 11% are partially vaccinated, about 30% of adults, aside from those who will be getting them due to vaccine mandates, are unlikely to get the vaccine any time soon. Since approval of the Pfizer vaccine for those aged 12-17 years on June 23, 2021,  57.9% of children aged 12-15 years, and 64.5% of children aged 16-17 years have received at least one COVID-19 vaccine dose. Only 50% have been fully immunized. On November 2, 2021 the CDC approved the Pfizer vaccine for children aged 5-11 years. While 27% of parents say they will immunize their children in this age range, 30% say they will definitely not have their children of that age get vaccinated. As of December 15, 2021 only 20% of these children have received at least one COVID-19 vaccine dose.

The September 2021 FDA and CDC discussions and decisions were about who to begin giving booster shots to, not whether or not booster shots are effective (they are) or will eventually be needed for everyone (they will but the timing is unknown). The FDA created an advisory panel (The Vaccines and Related Biological Products Advisory Committee). The committee has met multiple times to look at the existing evidence and made recommendations (see below).

Unlike other COVID disputes, such as vaccine mandates and ivermectin, that are not really controversial when you look at the facts, the decision to give booster shots in this country was not so straightforward. However, the arrival of the Omicron variant on the scene resulted in most experts recommending a booster.

There are four things about the immunity to COVID vaccination that are certain.

1. Immunocompromised people may not have an adequate response to the vaccine.
2. The immunity wanes over time.
   1. The effect is more pronounced for those with compromised immune systems and incomplete vaccination with Pfizer or Moderna mRNA vaccines.
   2. Waning immunity has increased the chance of getting mild to moderate disease, predominantly from the Delta variant. While the protection against serious disease, hospitalization, and death is persisting to previous variants as well as the Omicron variant.
   3. The time-frame is not predictable for individual people, but may be as little as 6-8 months for those exposed to Delta variant (which already decreased vaccine efficacy from 91%-78%) and may change with newer variants.
   4. One study showed that effectiveness of mRNA vaccines against mild disease seems to decline about 6% every 2 months.
3. COVID antibodies are a good way to measure protection against breakthrough infections, but low or undetectable antibodies do not indicate susceptibility to serious infections.
   1. Since antibodies are what protect us from infection, higher levels are more protective against getting COVID.
   2. After you have acquired a breakthrough infection, it is memory responses and cell-mediated immunity that also result from vaccination that are the primary protection from severe disease. This immunity lasts much longer and can’t be tested for.
4. Booster shots are safe and increase immunity to severe COVID disease, including to the Delta and Omicron variants. It has also become clear that boosters are the only way to slow the spread of the Omicron variant, which after only a few weeks is causing a surge in COVID infections and is already 94.5% of the COVID-19 strains in this country.

Although boosters of Moderna and Pfizer vaccines currently offer good protection from severe disease with the Omicron variant, the duration is still unknown. Moderna is now working on an Omicron-specific variant that may be available by March 2022.

A brief history of the COVID booster

In mid-August, the U.S. Department of Health and Human Services announced plans to offer COVID-19 booster shots — an additional dose of vaccine given after the protection provided by the original shot(s) has begun to wane (wear off) — to those who had previously received a full dose of the vaccine.

Subsequently, the FDA advisory panel that met September 17, 2021 recommended that a Pfizer COVID vaccine booster be offered to individuals age 65 and older and those at high risk for severe COVID-19 disease, such as immunocompromised patients. A separate committee at the CDC, the Advisory Committee on Immunization Practices, made recommendations on September 23, 2021.

People are considered immunocompromised if they:

• Are receiving active cancer treatment for tumors or cancers of the blood;
• Had an organ transplant and are taking medicine to suppress the immune system;
• Had a stem cell transplant within the last two years or are taking medicine to suppress the immune system;
• Have moderate or severe primary immunodeficiency, such as DiGeorge syndrome or Wiskott-Aldrich syndrome;
• Have advanced or untreated HIV infection; and/or
• Are undergoing active treatment with high-dose corticosteroids or other drugs that may suppress their immune response, like antimetabolites or monoclonal antibodies for autoimmune disorders.

Older Americans, especially nursing home residents were prioritized for COVID boosters for many reasons. Since Americans 65 years old and older were first to get their shots last year they will be the first to begin to have waning immunity. The immune response of adults 75 years old and older are less vigorous and seem to be waning much earlier than younger healthy adults. Elderly people who have been fully immunized have been found to be 4½ times more likely to become infected, and more than 10 times more likely to need hospitalization or die from COVID-19 than younger adults who were fully vaccinated. Compare this to unvaccinated people who are 11 times more likely to die from COVID. Full vaccination in adults over 65 years old reduced hospitalization for COVID by only 80% compared to 95% for fully vaccinated younger adults, and the older patients account for 70% of breakthrough infections that have required hospitalization and 87% of breakthrough deaths. Like waning immunity in general, there is no definitive age cut-off. For this reason some have suggested 60 years old, rather than the currently recommended 65 years old, as the cut-off age for giving boosters.

Other groups at higher risk for COVID-19 due to increased exposure were not included in the recommendation, most likely because, while they are at higher risk of breakthrough COVID infection, they may not be at risk for severe disease. This includes healthcare workers, and teachers. However, the final decision by CDC Director Rochelle P. Walensky, M.D., M.P.H. included this group. 

Recipients of the Pfizer vaccine who meet the criteria listed below and completed their series at least six months ago were approved for boosters on September 24, 2021. The FDA’s Vaccines and Related Biological Products Advisory Committee met on October 14 and recommended a booster dose of the Moderna vaccine for people 65 and older and for adults who are at high risk of severe illness because of underlying conditions or exposure on the job. The following day the FDA committee recommended a booster for all people who received the Johnson & Johnson COVID-19 vaccine. The CDC’s Advisory Committee on Immunization Practices met on October 21 and approved boosters for individuals in these groups who completed their Moderna series at least six months ago and for all individuals who received a Johnson & Johnson vaccine at least two months ago.

The final decisions by Dr. Walensky approved Pfizer and Moderna boosters for four groups:

1. Seniors 65 years of age and older and residents in long-term care settings. 
2. Individuals aged 50-64 years at high risk of severe COVID-19 disease due to underlying medical conditions, such as cancer, immunosuppression, diabetes, and heart or kidney disease. 
3. Individuals aged 18-50 years at high risk of severe COVID-19 disease if requested. 
4. Individuals aged 18-64 years whose frequent institutional or occupational exposure to SARS-CoV-2 puts them at high risk of serious complications of COVID-19, including severe COVID-19. This includes health care workers, teachers and day care staff, grocery workers, and those in homeless shelters, long-term care facilities, or prisons.

Pfizer booster shots began for immunocompromised people aged 18-64 years in early September. Pfizer and Moderna boosters are now available for those in the approved groups. Due to the low initial protection rate offered by the Johnson & Johnson vaccine, all recipients of this vaccine are eligible for boosters. In addition, moderately and severely immunocompromised people aged ≥18 years who completed an mRNA COVID-19 vaccine primary series and received an additional mRNA vaccine dose may receive an additional COVID-19 booster dose (Pfizer, Moderna, or Johnson & Johnson) at least 6 months after completing their third mRNA vaccine dose.

The remaining controversy of whether or not to give boosters to healthy adults and adolescents who most likely don’t need it yet was partially addressed on November 19, 2021 when both the FDA and CDC endorsed COVID booster shots for all adults 18 years old and older. With the discovery of the Omicron variant in South Africa and the evidence that it is spreading to other countries, the issue is no longer controversial. On November 29, 2021 the CDC encouraged all adults to get a COVID booster. This was followed-up with an expansion of eligibility of COVID vaccine boosters to adolescents aged 16-17 years on December 9, 2021 and adolescents aged 12-17 years and immunocompromised children aged 5-11 years on January 6, 2022. Unfortunately the rate of booster shots among previously immunized individuals is only 30%. Additional data will be needed to determine when boosters are needed for those aged 5-18 years.

Who is eligible for a booster shot? ​

Everyone 18 and older who is fully vaccinated against COVID-19 is eligible for a booster and should get one, the CDC says.

When?

• Two months after the single-shot Johnson & Johnson vaccine
• Five months after a two-dose Pfizer or Moderna vaccine

Additionally, adolescents aged 12-17 years and immunocompromised children aged 5-11 years who received the second dose of Pfizer’s COVID vaccine at least five months ago are eligible for a Pfizer booster.

Side-effects from the booster should not affect the decision to get a booster. A preliminary report published September 28, 2021 looking at side-effects in 12,591 subjects after their third booster showed only a slight difference in side effects between the second and third shots — local effects in 77.6% vs 79.4% and systemic effects in 76.5% vs 74.1%.

As to which type of booster to get, a recent preliminary study suggests that booster shots of the Pfizer or Moderna vaccine may be more effective than using the Johnson & Johnson vaccine. This resulted in the approval of a mix and match approach to COVID boosters, which is discussed in another article in this section.

Despite the emergence of the Omicron variant, many see a humanitarian component to the decision. They consider it an acceptable tradeoff for a few more American citizens to be temporarily at risk for mild to moderate infection until other countries are better protected. Other countries with high vaccine availability are considering this as well.

Public health experts, like some at the CDC, FDA, and those associated with The World Health Organization, look at the bigger picture of trying to control a worldwide problem. They are concerned that having 80% of the 4 billion doses given worldwide go to high- and upper-middle-income countries that make up less than half the world’s population will have a limited impact on the pandemic and result in many more deaths. In the U.S. it is more likely that politicians will put their constituents first and healthcare providers will want to do what they consider is best for their patients.

Although it may appear that postponing booster shots is contrary to ending the pandemic in America, there are advantages in doing so. Increasing global immunization is likely the only way to shorten the pandemic and reduce the likelihood of new variants developing like Delta and Omicron, which are more contagious and less affected by current vaccines and treatments. In a global society, reducing COVID hotspots worldwide will reduce our citizens’ chances of bringing COVID home.

Not giving boosters significantly in advance of the need for them will result in a better response to the booster and longer total time of protection.

While it is important to give boosters to our high-risk citizens to prevent serious illness and to healthy people 12 years old and older to slow down spread of the Omicron variant, we need to realize that this will have little impact on the pandemic while so many remain unvaccinated, both in this country and around the world. We need to continue to emphasize the need for our citizens to be immunized, but should also make sure surplus doses get to populations that can benefit from them and avoid further waste, such as the 15,000,000 unused doses that had been disposed of by September 2nd of this year.

The NeedyMeds website has a database of over 100 nationwide resources for those who have been impacted by COVID-19. For those looking for information on receiving a coronavirus vaccine, search online for your state’s requirements, area’s locations, and appointment availability. There may be options for children ages 12-18 to get vaccinated even if their parents don’t grant permission.