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Federal approval of a Covid-19 booster shot offers help for some Americans

Fears persist that a third shot may become the new marker of inequality in the pandemic.

A woman with long brown hair is wearing a surgical face mask, a black long-sleeved blouse, and light-colored trousers. She is standing with her arms folded straight against her body in front of her.
Oncology nurse Laura Griffith, who is immunocompromised, outside of UCSF Medical Center, where she works in San Francisco.
Sarahbeth Maney/The San Francisco Chronicle/Getty Images

US health agencies gave the go-ahead for immunocompromised people to receive a third dose of the Covid-19 vaccine late Thursday night, a high note amid increasingly alarming news about the delta variant. The decision is a big deal since those who have weakened immune systems are still vulnerable to becoming severely ill from the coronavirus, even if they are fully vaccinated. However, there is still one hitch: Immunocompromised people who received their previous shot from the Johnson & Johnson vaccine will not yet be eligible for a booster shot.

The Food and Drug Administration (FDA) and the Centers for Disease Control and Prevention (CDC) announced approvals of third booster shots of the Pfizer/BioNTech or Moderna vaccines for people with weakened immune systems. The green light came within 24 hours of the FDA’s recommendation.

“The FDA is especially cognizant that immunocompromised people are particularly at risk for severe disease,” said Dr. Janet Woodcock, the acting FDA commissioner, in a statement on the announcement. “After a thorough review of the available data, the FDA determined that this small, vulnerable group may benefit from a third dose of the Pfizer-BioNTech or Moderna vaccines.”

The decision was applauded by health officials and health care workers. “We are immediately pulling in those people, getting them the doses,” Dr. Marc Boom, president of Houston Methodist Hospital, which has a large organ transplant program, told NPR. Even those on the political right, where skepticism over the severity of the pandemic and dissenting voices against vaccinations have thrived, have softened their tune in light of the development regarding booster shots.

“This move is a big step in the right direction especially given the increasing number of vaccine breakthrough infections from the delta variant,” wrote Dr. Marc Siegel, a frequent Fox News guest who has been criticized for spreading misinformation about the pandemic. Siegel applauded the booster shot approval, but argued the policy should be expanded to other groups like essential workers and the elderly.

The Covid-19 booster shot approved by US health agencies is not a new vaccine. It is simply a third dose of the vaccine that is given to a person who has already been fully vaccinated. As NPR reported, the CDC recommends that a person get the same vaccine they received for their first two doses. So, for example, if you received the Pfizer vaccine for your first two shots, then you should also get the Pfizer vaccine for your booster shot. If it is not possible to get the same vaccine for your booster shot, an additional dose of the other mRNA vaccine (Pfizer/BioNTech or Moderna) is allowed.

Covid-19 booster shots work in conjunction with how our bodies build protection against threats. Biologically, our bodies contain helper T-cells that stimulate other cells called B-cells, which are crucial in producing antibodies. Certain types of B-cells act as memory cells that store the instructions needed for our bodies to produce a particular antibody. However, these memory cells aren’t activated; they’re waiting for a signal that triggers them to produce antibodies. As Sigal Samuel previously explained for Vox:

When you get a booster shot, it gives your memory B-cells that crucial signal to reengage. This can be useful whether the booster contains the original vaccine recipe or something different. If it contains the original recipe, it’ll amplify the signal, increasing the number of antibodies produced. If it contains a tweaked recipe, it’ll retrain the cells to recognize new features of the virus and produce antibodies, should you be exposed to the variant.

Studies have shown the initial two-dose regimen for the Covid-19 vaccination has lower efficacy in those with weakened immune systems, so another “boost” of the vaccine will likely help immunocompromised people build better protection against the coronavirus.

Currently, the Covid-19 booster shot is only recommended for “moderately to severely immunocompromised people.” While there are many kinds of people who may consider themselves at higher risk of serious illness from Covid-19, such as those having a pre-existing health condition, it is important to note that they are not necessarily the same as those who are immunocompromised.

According to the CDC, this category of people includes organ transplant recipients who are taking medicine to suppress the immune system, those undergoing cancer treatment, and people who are HIV-positive, among other criteria. The New York Times reported that about 3 percent of Americans are estimated to have weakened immune systems, and studies show initial vaccine doses have been less effective for immunocompromised people.

The vaccine efficacy rate for people with weakened immune systems is somewhere between 59 percent to 72 percent, much lower than the average person with a stronger immune system, who can expect 90 percent to 94 percent efficacy. Further studies revealed people who are immunocompromised benefited immensely from receiving a third dose of the Covid-19 vaccine, which is why it’s so important for them to receive a booster shot.

Despite the good news, the FDA also said they were unable to extend the authorization for a booster shot of the Johnson & Johnson vaccine due to insufficient data. It is unclear whether immunocompromised people who received the Johnson & Johnson vaccine will be eligible in the near future.

A close-up of the hand of a masked health worker as she inserts a needle into a vial of the Pfizer-BioNtech COVID-19 vaccine to prepare a dose for use.
An Israeli health worker prepares a dose of the Pfizer/BioNTech Covid-19 vaccine on August 13, 2021.
Ahmad Gharabli/AFP/Getty Images

Does this mean we are closer to booster shots for everyone?

In her statement last week, Woodcock reiterated that people who are not immunocompromised and are fully vaccinated are considered “adequately protected” and, as such, will not need a booster shot at this time. However, she emphasized that her team was continuing to work with agency partners to determine whether an additional dose for the general public is needed in the future.

But FDA and CDC approval on booster shots for immunocompromised people has reasonably spurred questions over whether we will soon get the go-ahead for booster shots to the general public, especially as Covid-19 infections and hospitalizations surge nationwide due to the much more contagious delta variant.

Most concerning are reports that the delta variant may be more successful against the Covid-19 vaccines, causing “breakthrough infections” or infections in people who are fully vaccinated. For these people, getting infected after being vaccinated can be overwhelmingly emotional.

“I was pretty shocked to learn I’d tested positive,” Daniele Selby, a writer based in New York City, told Vox. “I am fully vaccinated and have continued to wear masks … so to do all that and still get Covid-19 and feel ill has been pretty upsetting.” Others who have suffered breakthrough infections have had their circumstances politicized, like André Gonzales, who traveled between states for a funeral in early June after being fully vaccinated, and tested positive. “There have definitely been some that have tried to use [my] experience to discount the efficacy of the vaccines or to push unfounded cures on social media,” Gonzales said.

There is still much to be learned about Covid-19 breakthrough infections, but preliminary studies suggest there may be varying levels of risk of reinfection based on different vaccines. A recent study by Mayo Clinic suggests people who received the Moderna vaccine may be at a much lower risk of contracting a breakthrough Covid-19 infection than those who received the Pfizer/BioNTech vaccine. The study, however, has yet to go through a full review. It’s important to remember that breakthrough cases among people who are fully vaccinated are still uncommon, and even when they happen, data shows that these infections are at low risk of resulting in severe illness and/or hospitalization, underlining the benefits of getting vaccinated across the board.

With upticks in Covid-19 cases across the globe due to the more aggressive delta variant, experts say we may have to learn to live with the virus. The closest comparison to what we may expect from the virus in the future is the flu, which continues to cause tens of thousands of deaths each year in the US alone. But, over time, our society has largely managed to adapt to a world with the flu, thanks to the existence of an effective flu vaccine.

As German Lopez wrote for Vox:

While we still have to get more people vaccinated, at a certain point we’ll have to acknowledge we’ve done what we can. It might not be ideal, but we can learn to live with a vaccine-weakened version of Covid-19 — hopefully not too unlike how we’ve long dealt with the flu.

WHO Director-General Tedros Adhanom Ghebreyesus in a suit and tie speaking behind a podium desk with his hands in motion.
WHO Director-General Tedros Adhanom Ghebreyesus at a press conference in Kuwait, on July 28, 2021.
Jaber Abdulkhaleg/Anadolu Agency/Getty Images

Booster shot policies have exposed the world’s vaccine inequities

Globally, the United States is the latest country to allow booster shots for people with weakened immune systems, following countries like France, Germany, and Hungary. Some countries have already begun announcing plans to expand their booster shot policies beyond those with weakened immune systems.

The UK, France, and Germany have announced they will begin administering third Covid-19 doses to the elderly as soon as next month. Israel, which has also approved booster shots for those older than 60, has gone a step further, reportedly making plans to offer it to younger people, too. Israel was among the first to open up after lockdowns thanks to a strong vaccination program early on, but it is now experiencing another wave of Covid-19 infections, despite the country’s high vaccination rates.

The move to expand additional Covid-19 shots to the wider public in some countries has sparked criticism from World Health Organization officials, since the vast majority of poorer countries are still struggling to get residents vaccinated, even with first shots.

“I understand the concern of all governments to protect their people from the delta variant. But we cannot accept countries that have already used most of the global supply of vaccines using even more of it,” said WHO chief Tedros Adhanom Ghebreyesus. He urged governments to hold off on expanding booster shot programs until the end of September.

Officials from countries preparing to administer additional Covid-19 shots to the wider public have pushed back at the WHO’s criticism. Israeli Prime Minister Naftali Bennett argued that the results of the country’s distribution of booster doses among the elderly could be useful data for future booster programs across the world.

In any case, many countries are still lagging in vaccinations, partly due to a lack of access to vaccine supplies and partly because of poor infrastructure to distribute them quickly. According to Reuters’s world Covid-19 vaccination tracker, which uses data only from countries that report their vaccination figures, about 40 percent of people who have received at least one dose of a coronavirus vaccine are from high-income countries. And at least 34 percent of vaccine recipients so far are from Europe and North America.

As some wealthier countries begin moving toward distributing additional Covid-19 vaccine doses to their populations while other poorer nations still lag behind, and governments struggle to determine the best health protocols to keep people safe, the likelihood of disparities will continue.