You Should Get a Booster Now

America’s booster rules are far more confusing than necessary.

Vaccine needle
Alejandra Villa Loarca/Newsday RM/Getty

About the author: Ashish K. Jha, a physician, is the dean of Brown University’s School of Public Health.

As the air gets colder and drier and people in most of the United States move indoors, a winter spike in COVID-19 cases is beginning to materialize. The drop in new infections across the Deep South after a difficult summer raised hopes that the country could get through this winter without another surge. But that no longer seems likely. With less than 60 percent of Americans fully vaccinated, the U.S. remains vulnerable to renewed winter outbreaks. European countries with even higher vaccination rates are experiencing a substantial uptick in infections.

This is why all vaccinated adults would benefit from a booster. People who received the Johnson & Johnson vaccine should get a second shot as soon as two months after their first shot. The mRNA vaccines from Moderna and Pfizer yield a higher level of immunity against infections early on, but it gradually wanes over time. For young, healthy people, breakthrough infections are usually mild. But for older people, they can be deadly. And breakthroughs can lead to further spread, albeit less often than infections among unvaccinated people.

So far, official U.S. policy has restricted boosters to the medically vulnerable and those at high risk of exposure to the coronavirus. But in light of new evidence, the CDC should expand its recommendations to include all adults six months after vaccination. The evidence is so compelling that several states, including Colorado and California, as well as cities such as New York are advising adults to ignore CDC restrictions and get a booster.

Right now, infections are raging among unvaccinated people in Europe and the U.S.—but they are spilling over to the vaccinated as well. Recent CDC data suggest that unvaccinated people are about six times more likely than vaccinated people to get infected and 11 times more likely to die of COVID-19. Applying these ratios to current U.S. data suggests that about 12,000 vaccinated people are becoming infected and 100 are dying every day. While most of those infections come from unvaccinated carriers of the virus, some spread is occurring among the vaccinated too.

The steps we’ve taken in the past to prevent new infections—stopping gatherings, asking people to stay home, shutting down restaurants and bars, mandating masking on a broad scale—are less and less realistic now. Twenty months into the pandemic, neither the public nor our political leaders are likely to adopt these interventions. And that’s where boosters can help.

Israel’s response to the problem is encouraging. That country has administered third shots to about half of its population, and its data demonstrate that boosters restore protection against infections, offering approximately 95 percent protection against infection from the Delta variant, a remarkably high degree of immunity. These data also indicate that boosters reduce hospitalizations and deaths, and seem to boost protection for every age group. Israel has made boosters available to all adults.

Doing the same in the United States makes sense as a matter of both minimizing risks to individuals and protecting the health of the population as a whole. Let’s consider a healthy, 30-year-old vaccinated woman. It’s true that the benefits of a booster for her individually are modest: With waning immunity, she’ll be at risk of a breakthrough infection when she encounters the Delta variant, but for her that would likely mean a few days of misery and full recovery, with a small (albeit not zero) risk of severe disease or long-term complications. Still, getting a booster dramatically reduces her risk of a breakthrough infection and further lowers her risk of getting sick. And the risk of that booster? Trivial. Millions have gotten a booster and have had few side effects. And given that we have millions of doses widely available for free, and likely to go to waste if not used, the individual risk-benefit calculation clearly favors getting a booster.

The population-health perspective is even more compelling. That healthy 30-year-old might want to visit older relatives or be around an immunocompromised friend. While her risk of spreading the virus if infected is low, it would be much lower if she were boosted. Her immunity would provide a strong wall of protection against viral spread.

There are two main arguments against boosting adults, neither of which stands up to scrutiny. The first is that if the spread of the coronavirus is mainly fueled by unvaccinated Americans, why not focus just on them? Of course public-health officials should keep trying to win over the unvaccinated—but making boosters widely available needn’t divert attention from first shots. The U.S. can do both. There is no trade-off.

The second argument against boosters focuses on global vaccine equity: Before Americans get a third shot, some argue, vaccines should be sent to where people are struggling to get their first shot. Yet the world is producing about 30 million vaccine doses a day. The U.S. currently administers about 700,000 boosters daily. Even if this number doubles, it would still be less than 5 percent of the global vaccine supply. The U.S. has sent 250 million doses abroad and is planning on sending another 500 million doses in the upcoming months. Nearly 100 million doses are sitting on shelves across America; they cannot be recaptured and sent abroad. Either we use those doses here or we throw them away.

If anything, universal boosters may be a crucial part of addressing severe health inequities in the U.S. Existing booster policy gives individuals primary responsibility for determining their own eligibility and making an appointment for a shot. This favors highly privileged, high-information Americans. Complexity breeds inequity. The current rules of eligibility are confusing: For example, what counts as “high risk” or “high exposure”? When public-health guidelines leave room for interpretation, the result is usually regressive; the most vulnerable people receive less protection than more privileged communities. A winter surge is likely to be most devastating for communities of color and the poorest Americans. A clear, emphatic, nationwide booster policy would save lives.

The underlying challenge is that our public-health infrastructure was designed for noncrisis conditions. FDA and CDC procedures prioritize slow, careful analysis of evidence only after companies formally submit their data. This makes a lot of sense when considering a new hair-loss drug, but not during a fast-moving pandemic. In the current situation, the federal agencies should consider all available data and make a determination proactively to allow boosters for all adults, rather than defer to an outdated, overly bureaucratic process. The science is clear: People should go get a booster. America should banish any confusion on the subject.