Confused Messaging About Boosters Might Cause 5th Wave of COVID

The news of COVID-19 surging in Eastern Europe is a dire warning to the United States. Austria with 65% of its population fully vaccinated and Germany with 68% of its population fully vaccinated are entering a fifth wave of infections. The vast majority of vaccines administered in Germany were Pfizer/BioNTech along with Moderna. Few individuals in Germany have had a booster. Austria just started to rollout boosters on November 2, 2021.

Even Iceland and Ireland with over 90% of their adult population fully vaccinated are undergoing a surge. Ireland has had a significant delay in administering boosters and Iceland is just starting booster distribution.

This does not bode well for the US which has only 59% of its population fully vaccinated.

Because of waning immunity Israel started offering boosters to those over 60 years of age on July 30, 2021, and then extending this to all adults over 50 a few weeks later. By August 28, 2021 children as young as 12 were being encouraged to obtain boosters.

In contradistinction, the US offered boosters starting on October 21, 2021 to those over the age of 65 and those having underlying medical conditions or at high risk of exposure. At the same time many policy advisors were downplaying the risks of COVID-19 in individuals who were not at risk for hospitalization or death. This strategy ignored the fact that many of the so called “mild” cases often progress to long COVID-19 or can later develop cardiac abnormalities as a result of occult infections.

The delayed and restricted use of boosters in the US was the result of guidance by the Centers for Disease Control and Prevention (CDC) and the Food and Drug Administration (FDA) and blunted an effort by the White House to offer boosters to everyone. The CDC at one time considered changing the definition of “fully vaccinated.” There is growing evidence that fully vaccinated should be defined as having 3 doses of an mRNA vaccine. Some states, including California and Colorado, have overridden CDC guidance and are currently offering boosters to all vaccinated adults.

Not only is the US at risk because of absent or incomplete immunization in a large percentage of its population, but about 1 in 30 individuals have an immune deficiency. Those with organ transplants and hematological malignancies are at a significant risk of not having protective immunity after vaccination. Only about 20% of solid organ transplant patients have measurable antibodies after a second vaccine dose. The good news is that a Moderna booster (third vaccine dosage) has been reported to produce an immunological response in 49% of those who did not develop a response after the second dosage.

It also needs to be remembered that vaccination rates and the percentage of dead-end hosts which will stop viral spread are not homogeneously distributed throughout a state or country. The unvaccinated are part of a social group with similar thinking and tend to congregate together promoting viral spread (and mutations) even in regions with high vaccination rates.

The low percentage of the US population who have received at least 2 doses of an mRNA vaccine is not only an embarrassment but also a reflection of the dysfunction in our country. It is placing our nation in great peril. We have fallen behind 50 other countries, including third world countries such as Cambodia where 80% of the population is “fully vaccinated.” It is apparent that a booster is also needed in most of our population to protect against infection and mitigate spread. Unfortunately, our nation is set up for another surge of Delta over the winter holidays. Scott Gottlieb, MD, the former head of the FDA, stated that “the confusing message around the boosters … may end up being one of the biggest missed opportunities in this pandemic…. [W]e now see very clear evidence of declining vaccine effectiveness over time.”

Finally, the CDC needs to provide comprehensive real-time data on the status of the COVID-19 pandemic in the US. Currently, data on immunization status of patients with infections and hospitalizations is over 2 months old. We also need data on reinfections and expanded viral sequencing in order to detect the emergence of variants. This will enable us to not only better predict the trajectory of the pandemic but to regain the trust of the public by giving more accurate guidance which can have a profound impact on their daily lives.

The toll of this pandemic on the US has been profound. Over 750,000 deaths directly related to COVID-19, along with many other non-COVID-19 patients who have not been able to obtain timely medical care for potentially life-threatening diseases because hospitals were filled. The strain also is placing an economic toll on many, exemplified by the Medicare announcement of an over 14.5% increase in Part B premiums and deductibles.

The evidence is clear, and the path evident, we must expand our efforts to stop viral spread, including the upgrading of indoor ventilation along with the use of masks by all in public settings and expansion of home testing. But above all we need to offer boosters to all adults who are more than 5 to 6 months post receiving an mRNA vaccine.