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Who should get a Covid-19 booster shot right now?

Three big questions about booster shots, answered.

Hattie Pierce, 75, receives a Pfizer Covid-19 vaccine booster shot from Dr. Tiffany Taliaferro at the Safeway on Capitol Hill in Washington, DC, on October 4.
Tom Williams/CQ-Roll Call Inc. via Getty Images
Dylan Scott covers health care for Vox. He has reported on health policy for more than 10 years, writing for Governing magazine, Talking Points Memo and STAT before joining Vox in 2017.

It may be time for your Covid-19 vaccine booster shot.

The Food and Drug Administration has now authorized additional doses of all three Covid-19 vaccines in the US — Pfizer/BioNTech, Moderna, and Johnson & Johnson — for certain higher-risk groups and has said that booster shots don’t have to be the same brand as the first round of vaccination. The CDC has seconded those recommendations.

The government’s recommendations for booster doses are based on different subgroups’ risk from Covid-19; thus far, boosters are only recommended for older adults or people at higher risk because of their health or occupation. Experts have debated to what extent boosters are appropriate for everybody, given the evidence of persistently strong protection against severe illness for many people. But most seem to agree an additional dose makes sense to increase immunity for people considered more vulnerable to the virus.

While boosters still aren’t technically recommended for everyone yet, the groups already okayed by the FDA and Centers for Disease Control and Prevention for booster shots are quite broad and cover much of the adult population. Everybody over age 65 is eligible for an additional dose — that’s 54 million people. People with certain medical conditions such as heart disease (as much as 48 percent of adults) and people who are obese (about 42 percent) are also eligible for a booster. So are people in occupations deemed to be higher risk, such as first responders, manufacturing workers, teachers, and grocery store employees.

The bottom line for now: If you were vaccinated at least six months ago with the Pfizer/BioNTech or Moderna shot and you’re at higher risk for Covid-19 based on your age, job, or medical history, it’s recommended that you receive a booster. So should anyone vaccinated at least two months ago with the one-dose Johnson & Johnson vaccine, according to the FDA.

Who is recommended for a booster shot?

The FDA has approved booster shots of the Pfizer/BioNTech, Moderna, and J&J vaccines, and the CDC has finalized matching recommendations for who should receive a booster.

Under the FDA’s authorization, the following people are eligible for an additional Covid-19 vaccine dose:

  • Any person over age 65 who initially received either the Pfizer/BioNTech or Moderna vaccine
  • Any person over age 18 who initially received the Johnson & Johnson vaccine
  • People ages 18 to 64 who initially received either the Pfizer/BioNTech or Moderna vaccine and whose health puts them at higher risk from Covid-19
  • People ages 18 to 64 who initially received the Pfizer/BioNTech or Moderna vaccine and whose job puts them at higher risk of exposure to Covid-19

The lists of medical conditions and occupations that qualify for a booster shot extend eligibility to a lot of Americans. Those medical conditions include not only heart disease, diabetes, and cancer but also depression and pregnancy. High-risk jobs include the people in the food and agriculture industry, nursing home workers, and US Postal Service employees. Check the list — more people are eligible than you may think.

Age is the strongest indicator for a booster shot, according to the experts I’ve spoken to. Even those who think the case for booster shots for younger and healthier people is not as strong agree that people over 65 would likely benefit from an additional dose. Most experts also support boosters for immunocompromised people, though the vaccines are still not as effective for those people to begin with.

There is less consensus among experts about workers in jobs considered to be high risk, if they don’t already qualify because of age or health. Experts stress that research continues to show strong protection against severe illness for younger people without any significant medical conditions. But senior government health officials have insisted on including those workers in the groups eligible for a booster shot.

Sandra Lindsay gets a Pfizer booster shot at Northwell Health in New Hyde Park, New York, on October 6. Lindsay, an intensive care unit nurse at Long Island Jewish Medical Center, became the first American to receive the Covid-19 vaccine in December 2020.
Alejandra Villa Loarca/Newsday RM via Getty Images

For the eligible people whose first doses were either the Moderna or Pfizer/BioNTech vaccine, they can receive their next dose at least six months after their initial vaccine course was completed, the FDA said. For people whose first dose was the J&J vaccine, they can get a booster shot two months after their first shot.

The federal guidance matches what many experts have said is appropriate based on the current scientific evidence. There have been indications of the Covid-19 vaccines waning in effectiveness over time and against the delta variant. But the protection they provide against severe disease — resulting in hospitalization or death — remains strong for many people.

The exceptions are older people, who have seen a greater drop in efficacy over time, and people with compromised immune systems, for whom the vaccines are often not as effective to start with. They are the focus of the booster guidelines, along with workers in higher-risk settings.

What about mixing and matching different shots?

All of the Covid-19 vaccines offer good protection against severe illness, but they are not equal.

The Moderna vaccine has held up the best over time, including since the delta variant became dominant. Pfizer/BioNTech performs the next best, while Johnson & Johnson was the weakest of the three in its original one-dose regimen (though it has not seen much waning over time).

Those differences have led some people — J&J recipients, in particular — to wonder whether they should get a dose of one of the better-performing vaccines for their booster shot.

As the Atlantic reported last week, research from the National Institutes of Health (NIH) has found the people who received a first dose of J&J and a second dose of Moderna or Pfizer/BioNTech showed higher antibody levels than the people who got J&J for both doses. Antibody levels are not the only metric by which immunity is measured, but they are a useful proxy.

The evidence is not as clear about whether it’s better to get a Moderna booster if you previously received the Pfizer/BioNTech vaccine (or vice versa) because the NIH study used a full dose of the Moderna vaccine for its booster, whereas, in the real world, the Moderna booster will be a half dose.

The new FDA guidance does say that people should be okay mixing and matching different vaccines. Generally speaking, they can get whichever booster shot they like if they fall in one of the subgroups recommended for an additional dose and sufficient time has passed: again, two months for J&J recipients or six months for Pfizer/BioNTech or Moderna recipients.

Different vaccines also have different side effects, another consideration for booster shots. Younger men who receive the Pfizer/BioNTech or Moderna mRNA vaccines have been found to be at a slightly higher risk of heart inflammation. Younger women who receive the J&J vaccine may be at a somewhat elevated risk of a rare blood-clotting problem.

Both of those side effects, though serious, have been rare, and the FDA said the expected benefits of a booster shot for each of the vaccines outweigh the risks.

Wanda Shaffer, 83, got her Pfizer booster shot at a California McDonald’s in September, as the California Department of Public Health and local McDonald’s franchisees held pop-up vaccine clinics at locations throughout Southern California.
Francine Orr/Los Angeles Times via Getty Images

Should I get a booster shot?

First off: The vaccines work. Recent waves of Covid-19 hospitalizations and deaths have been concentrated in the remaining unvaccinated population. People who receive a vaccine are less likely to contract Covid-19 in the first place, much less likely to develop severe symptoms, less likely to transmit the virus to other people, and less likely to develop long Covid.

But the vaccines aren’t perfect. There are going to be breakthrough cases. For some people, they don’t work as well. The recent death of former Secretary of State Colin Powell — who was fully vaccinated but immunocompromised because of blood cancer — served as a reminder that some people remain at risk so long as the virus is still circulating.

The current federal guidance is concentrated on those people, to provide them more protection ahead of the winter. In the best-case scenario over the next few months, at-risk people get this additional immunity, more people get their first vaccine dose, and the virus slows down without new variants emerging. We should see fewer deaths than we did during last winter’s devastating wave.

Still, Covid-19 isn’t going to disappear entirely, and experts expect booster shots may eventually be authorized for most people. A lot of Americans had already gone ahead and gotten an extra dose before the FDA officially approved it.

Wafaa El-Sadr, a professor of epidemiology and medicine at Columbia University, told me she thought people who are already eligible should get their booster “as soon as possible.”

Other people might consider it, she said, if they were expecting to congregate with a lot of others during the holiday season or if they have to spend a lot of time around unvaccinated people or individuals whose vaccination status they don’t know.

Covid-19 is here to stay, and booster shots are a reflection of that reality. They are one way to make it more palatable to live with this disease.