The paper is thoughtful. The reporting on it is reckless. An accurate headline would be: "Vaccine experts: Widespread booster mandates aren't needed now," or perhaps "recommendations"
There's a line between:
* Mandatory.
* Recommended.
* Allowed.
* Banned.
If I am flying to do humanitarian work in Vietnam tomorrow, I absolutely need a booster shoot. Right now, the only way to get that is to go to a state which doesn't require ids for vaccines, and get a shot.
The article discusses that boosters are clearly still appropriate in some circumstances:
"Boosting could be appropriate for some individuals in whom the primary vaccination, defined here as the original one-dose or two-dose series of each vaccine, might not have induced adequate protection—eg, recipients of vaccines with low efficacy or those who are immunocompromised2
(although people who did not respond robustly to the primary vaccination might also not respond well to a booster)."
Not quite sure why you absolutely need the booster shot, could you explain more there? Is that personal preference. Having both almost entirely eliminates the risk of hospitalisation from the other strains.
People who got vaccinated five or six months ago are seeing their immunity rate drop to around eighty percent. That's double the risk compared to a fresh vaccination.
Studies have primarily observed a modest decline in effectiveness among older people and the immunocompromised, which is why some jurisdictions have recommended boosters for these people (Israel, California). There is a reason boosters have not been approved anywhere for the general population, and that is because so far the data does not indicate they are necessary.
Necessary and useful are two vastly different things. My state is throwing expired vaccine into the garbage. I'd take a booster even if it only made me five percent safer.
This is the part I don't understand. There is an oversupply of vaccines, why not let me go get my 3rd shot if it's already here? I understand the desire to take those "extra" vaccines and ship them to other countries, but if the vaccine is already distributed out around the country, it would be more expensive and hazardous to collect them back up safely than to just administer boosters to those who want it.
The vaccines that are already distributed were distributed considering the original plan of only two doses per person. More vaccines would need to be ordered to get enough for a third dose.
Right, but if you order enough to give 100 people 2 doses (200 doses) and only 50 decide to get the vaccine, you have 100 doses left over.
The COVID vaccines have essentially a 6-month shelf life before they are considered expired [1]. So if the example doses above were delivered several months ago, the period for collecting and transporting them to another country is pretty small.
Instead of throwing away this unused vaccine, it could be given to people who are willing to participate in a booster study or would like to have it, without making the booster mandatory. Obviously a mandate wouldn't work for the excess supply sitting around.
That article indicates the Pfizer vaccine loses 6% effectiveness every two months within a six month period. It doesn't say anything about what happens after six months.
Is that entirely true even for people who have a life outside their own home? I would assume being constantly bombarded by the viruses outside would keep their immunity higher than expected?
Well, I'm not flying to Vietnam tomorrow, so I'm not claiming I personally need a booster shot.
However:
- Vietnam is an epicenter right now, so my odds of catching COVID would be high.
- They are well beyond hospital capacity, so if I do have a serious case, it's uncertain I'll receive quality care (and if I do, I'm taking a bed from someone else)
We don't have full data, so the right way to think about this is with expected outcomes based on best available data. Best available data, in this scenario, places the likely reduction of risks of COVID19 as a much greater risk reduction than any potential risk of vaccines:
- We do have multiple studies about how immunity wanes over time from vaccination. Those provide better ground-truth data than theoretical arguments.
- We also have some estimates of breakthrough rates, and severity of infection
We don't have good data on long COVID post-vaccine, so that's a place we need to make an educated guess and rely on theoretical arguments.
You can plug whatever sane numbers you want, but in this scenario -- humanitarian work in an epicenter with limited hospital capacity -- a booster shot makes sense.
For other scenarios -- for example general population -- whether a booster makes sense is still often within the very large error bars of the limited data, and reasonable people can disagree, much as the authors of the Lancet article and the CDC currently do. Once more data rolls in, we'll know.
> We do have multiple studies about how immunity wanes over time from vaccination. Those provide better ground-truth data than theoretical arguments.
I believe the studies you're referring to are those that address efficacy against symptomatic infection, not severe illness. Unless you're in a high-risk group because of age or comorbidities, with two doses of an mRNA vaccine within the past 8 months, to my knowledge all studies to date indicate that the average person's protection against severe illness and hospitalization is exceedingly high. This is probably related to the T and B cell immunity created by your body's response to the vaccines, which are more difficult to measure than antibody titers.
I traveled to/from a hotzone in Asia at the beginning of the pandemic and from Asia to the US and back to get vaccinated. My opinion as an expat and avid traveler is that if you have any concerns about your ability to receive adequate care in the case that you get sick, you should reconsider travel at this time. Since the vaccines clearly do not provide sterilizing immunity and everyone's immune response is different, there really are no guarantees, especially if you're going to be in environments where your exposure is high (both in terms of number of contacts and contacts that could lead to exposure of high viral loads).
This is my clear (amateur) conclusion as well. The exposure amount and dose varies, exposure in high-density hot zones is high risk and the cumulative dose does seem to pose some additional risk, as does the risk that you may not be able to receive a high level of clinical care in various areas.
I'm not necessarily talking about adventures in southeast asia there either.
- How much do you worry about spending two weeks in a hospital?
- How much do you mind memory lapses and brain fog from long COVID?
From what you wrote, it's clear we have at least somewhat different value systems. Since you're an avid traveler, you should realize that's good, common, and healthy.
The subtle implication of your comment seems to be that I value my life and health less than you do? If so, I think that's unfair. But I'm happy to roll with it. If, in the face of substantial evidence that two doses of one of the mRNA vaccines remain highly effective at preventing hospitalization and death 8 months on, you still cannot tolerate the potential that you could end up in a hospital in a developing country, suffer from long COVID following infection and/or die, logic dictates that you should reconsider travel.
You might strongly believe or suspect that a booster will provide meaningful additional protection to you, but the ongoing booster debate reflects the fact that at the current time, there is no conclusive proof that a booster will definitely reduce risk in healthy already vaccinated individuals, nor has any potential risk reduction that booster proponents believe exists been conclusively quantified.
Put simply, just because one believes that they have meaningfully increased protection from a booster does not necessarily mean that they actually do. Science will eventually tell us but the data isn't in yet.
I don't think you've traveled so much if you think that's the implication, or at least not for long enough to soak in how values differ between cultures.
No. That's not the implication.
I don't know you well enough to tell you what the differences in our value systems are.
Since you do ask, if I were to speculate, I would guess you value your life and comfort more than I value mine. I was never fearful of dying of COVID, or of hospitalization, even pre-vax. Americans place an exceptionally high value on their own life and comfort relative to most cultures. I've also been in several hospitals in developing countries, and that's also not something which has really concerned me.
On the other hand, I suspect I am much more concerned about long COVID than you are.
And no, we don't know much for sure about COVID, but we have to work from best available evidence. If there's e.g. a 50% chance that a booster shot increases protection from 30% breakthroughs to 15%, and a 50% chance it does nothing, that means I've reduced my odds of breakthrough by (30-15)*50% = 7.5%.
Ha. So now you're questioning how much I've traveled. :eyeroll:
I don't know you so I won't pretend to know how much you value anything, how much you've traveled, etc. but you seem to be shifting your position for the sake of arguing. For example, you're now saying you're fine with hospitals in developing countries, but your original comment expressed concern about your ability to receive quality care in Vietnam:
> They are well beyond hospital capacity, so if I do have a serious case, it's uncertain I'll receive quality care
As for:
> And no, we don't know much for sure about COVID, but we have to work from best available evidence. If there's e.g. a 50% chance that a booster shot increases protection from 30% breakthroughs to 15%, and a 50% chance it does nothing, that means I've reduced my odds of breakthrough by (30-15)*50% = 7.5%.
In other words, your "absolute" need for a booster shot is based on numbers you've pulled out of a hat.
I think you are trying to overanalyse and overrule the experts here.
Experts are saying that with the regards to the whole population currently community wide booster shots are not needed. It may not apply to each individual case (such as immunocompromised etc., or people with very specific risk, like those going to Vietnam) but this was never to be meant an individual assessment. Many people are confusing these two things. Even though it does not apply for majority of readers, trying to imagine a different situation for a specific individual is not necessary.
That's unfair. I'm trying to overrule bad reporting, not experts. The experts made a nuanced point which seemed reasonable, and the reporters screwed it up.
Mostly in agreement - I would note that the Lancet article gives a few arguments with citations as to why the vaccine efficacy decreases might be statistical artifacts, and so I think you may be a little over-confident on your bullet there. But I agree that there is data on both sides, and strongly agree with your general approach of accounting for the possibility that vaccine efficacy could be waning in your risk model and updating behavior accordingly.
> Vietnam is an epicenter right now, so my odds of catching COVID would be high.
ho chi minh is an "epicenter" according to Vietnamese authorities (who have always taken a much stricter, "zero-covid-adjacent" approach to managing covid). While there is always risk, the case-rate is roughly the same as Germany & France (neither of which are in lockdown) & much lower than other western states like the US & UK. The entire country is in lockdown because this is an all-time high by Vietnamese standards (Vietnam have fared similarly to NZ in terms of case-rates before now), despite case-rate in e.g. Ha Noi being low, further mitigating risk factors.
So no I don't think the odds of catching it would be significantly higher than wherever you currently reside, unless your humanitarian work is specifically treating covid patients, in which case of course you should get a booster but the destination country is completely irrelevant.
Points about hospital capacity are obviously still relevant, but that's not necessarily going to be impacted by boosters as much as vaccination in general: full vaccination rate in Vietnam is only ~5% due to supply issues that are only exacerbated by over-subscription to boosters in western states.
> “ recipients of vaccines with low efficacy or those who are immunocompromised2 (although people who did not respond robustly to the primary vaccination”
How do we measure it? Like is there a way to know through antibody tests?
If you want to know whether you need the booster or not, and you're in the US, the spike antibody test ("COVID-19 Blood Spike Protein AB") falls under Covid testing, so if you have insurance it's covered with no out of pocket expense. You can get it at most urgent care clinics, and then you can find out exactly what your antibody levels are.
I got my Moderna 2nd shot in February and my antibody levels are 1483 (out of 2500) so I am satisfied and not in any hurry to get the booster.
1. Determining how much real-world protection you have against infection, hospitalization and death is a lot more complex than antibody titers. Everybody is different, every infection is different and even in the healthy population, everyone's immune response to the vaccine will be somewhat different. My understanding is that it's entirely possible a person with antibody levels lower than yours might be at lower risk than you in the real world because of their health compared to yours, the strength of their immune system compared to yours, etc.
2. Antibodies are only one part of the immunity equation. In the long run, T and B cells are probably just as important if not more important than antibodies. This is another area where it's reasonable to expect that YMWV when you get vaccinated.
3. My understanding is that in the context of vaccines these tests are used primarily to assess whether an individual had an immune response to the vaccines, not to make a meaningful determination of how much protection they have (because there's no "formula" for this).
4. It appears from the Delta-related data that any relationship between antibody titers and risk is influenced by variants.
5. We shouldn't rule out environmental factors in the protection equation. For example, if you work in an environment where you're exposed to high viral loads on a regular basis, it seems possible that you could be at higher risk than somebody who isn't even if you have higher antibody titers.
Even if there is a good answer to "How do we measure it?" it might cost more to know than it does to administer a third shot.
There remains an argument (or a "rebuke," as the article puts it) that first world countries that are well placed to administer booster shots to the fully vaccinated should instead contribute to faster vaccination worldwide, even on a self-interested basis in order to reduce the cases where new variants can emerge.
But that is a tenuous argument. A simple first question unanswered in the article is: How much of the unvaccinated population lives where vaccines requiring ULT freezers can be distributed? It may be that every place well equipped to use those kinds of vaccines will do best to get their total vaccination rate as high as possible and administer booster shots to reduce breakthrough infections, so normal activity can resume. Supply chain disruption is not a trivial problem. Having safe workplaces is not a luxury.
The most important trend (IMHO) they point out is that effectiveness vs. severe disease does not drop or barely drops. They claim: To date, none of these studies has provided credible evidence of substantially declining protection against severe disease, even when there appear to be declines over time in vaccine efficacy against symptomatic disease.
However, the graph they provide doesn't seem to be based on data that appears reasonably chosen (that could be my limitaiton, sure).
They refer to appendices (which are here: https://www.thelancet.com/cms/10.1016/S0140-6736(21)02046-8/...), and specifically table S4 appears to be the basis for their graph D. In it, they split same-paper sources into early vs. late effectiveness with respect to hospitalization. Four sources are relevant.
- #5: Health IM of. Two dose vaccination data. 2021. 2021 - I can't find this source.
- #41 https://pubmed.ncbi.nlm.nih.gov/34401884/ - ...but this paper has huge error bars and additionally the average effectiveness jumps up and down just to underline that the source not only claims to be noisy but appears to be so too. There's just not enough clean data here for any conclusion (wrt to a declining efficacy vs. severe disease).
- #42 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8389393/ - this paper seems to have solid data, but it simply doesn't include data on when people were vaccinated, and it uses definitions like this: "Hospitalizations among persons with breakthrough infection were defined as new hospital admissions among persons fully vaccinated on the reporting day." - in other words, a mixture of people that are vaccine-protected, and those that have had the jab but not the time to become protected. And the paper does not track how long ago people were vaccinated - so how does the lancet article then try to split this into early vs. late groups? Presumably by calendar date, which I don't think is reasonable; at least not reasonable enough.
- #43 https://www.medrxiv.org/content/10.1101/2021.08.24.21262423v... - and I'm just going to believe they copied the results correctly, but notably that paper concludes: "The efficacy of the vaccine against severe disease for the 60+ age group also decreases; from 91% to 86% between those vaccinated four months to those vaccinated six months before the study. The corresponding efficacies for the 40-59 age group are 98% and 94%. Thus, the vaccine seems to be highly effective even after six months compared to the unvaccinated population, but its effectiveness is significantly lower than it was closer to the vaccination date."
So when they say this: "Given the data gaps, any wide deployment of boosters should be accompanied by a plan to gather reliable data about how well they are working and how safe they are. Their effectiveness and safety could, in some populations, be assessed most reliably during deployment via extremely large-scale randomisation,17 preferably of individuals rather than of groups." - that makes sense; I can understand that.
But this on the other hand: "To date, none of these studies has provided credible evidence of substantially declining protection against severe disease, even when there appear to be declines over time in vaccine efficacy against symptomatic disease." - seems to be contradicted by their own sources.
Given the data they themselves cite and in addition the many more sources demonstrating that protection from infection wanes (not just antibody levels), it seems implausible to assume that protection from severe disease won't wane significantly as well, even if they're right in saying we don't know for certain or by how much.
However, even the waning already demonstrated in the #43 data set represents approximately a 50% increase in the number of hospitalizations and an increase in transmissibility after less than 8 months. Saying it's "still very high" is surely true, but the way they paint boosters as somehow plausibly unnecessary smells like motivated reasoning to me.
They clearly make the case for greater third world vaccination; as an ethical argument that makes sense. But the claim that boosters likely won't be useful strikes me as being a little creative with their sources.
Furthermore, while the article goes to great lengths to question the utility of booster shots, it does not similarly make the case that avoiding booster shots will actually materially increase vaccinations elsewhere. And while that seems plausible at first glance, there are also reasons to think that's not really true: e.g. are the boosters going to be diverted from production or will they simply be usage of already distributed shots that weren't taken up by the vaccine hesitant (which could be logistically impossible to redistribute in time)? How many people will be both eligible and willing to take a booster, and how does that compare to the number of exported doses - it might not amount to much? Is the timing of the boosters early enough that there will still be a significant export crunch? Is there really a tradeoff here at all, or will by the time boosters are used in significant numbers (say 100 million) other production be ample too?
I don't think the article really makes a very thoughtful case, at all. It doesn't really support the notion that boosters will impact supply elsewhere by the time they're deployed, and it's claiming evidence supporting booster utility is slim, but it's not quite as slim as they make out, and again - by the time boosters are widely used, if the evidence we do have so far continues to build in that vein - there will be ample evidence then.
Sure, there is a plausible future in which boosters have unexpectedly low utility, yet high uptake, and are mostly doses from new production as opposed to older, already locally distributed doses, all while third-world vaccination remains highly supply constrained. That's a future to avoid. But the paper doesn't make the case it's a likely future, nor even that it'd be hard to see it coming and thus needs action today.
There's a line between:
* Mandatory.
* Recommended.
* Allowed.
* Banned.
If I am flying to do humanitarian work in Vietnam tomorrow, I absolutely need a booster shoot. Right now, the only way to get that is to go to a state which doesn't require ids for vaccines, and get a shot.
The article discusses that boosters are clearly still appropriate in some circumstances:
"Boosting could be appropriate for some individuals in whom the primary vaccination, defined here as the original one-dose or two-dose series of each vaccine, might not have induced adequate protection—eg, recipients of vaccines with low efficacy or those who are immunocompromised2 (although people who did not respond robustly to the primary vaccination might also not respond well to a booster)."