Opinion | Allowing a second booster dose in the COVID-19 vaccine is a change in the fight against the pandemic

The FDA announcement, and the subsequent approval by the Centers for Disease Control and Prevention (CDC), has caused mixed reactions. Some criticized the process: Unlike prior authorizations for vaccines, independent advisers to the FDA and CDC have not yet given their opinion, and, in fact, are scheduled to meet next week to discuss this issue. Others applauded the swift decision, especially since the CDC has just reported that the extremely contagious BA.2 subvariant of omicron has become the dominant strain in United States.

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The medical community itself is divided on whether a fourth dose is necessary. That’s because there is no consensus on the exact purpose of vaccination. Is it to prevent serious disease or to reduce any symptomatic disease?

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If the goal of vaccination is to prevent hospitalization and death, the vaccine plus a booster should suffice. A CDC study revealed that the application of two doses generated an 88% reduction in the probability of needing a respirator or dying; three doses increased protection to 94%. During the period in which the original omicron strain was dominant, the efficacy of the two doses dropped to 79%, while that of the three doses remained at 94%.

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If the goal is to reduce any COVID-19 infection, the matter is more complicated. On the one hand it is clear, from a analysis extensive in California, that the efficacy of three doses against omicron declines over time (although protection against hospitalization remains strong). But even if preliminary data from Israel show that a fourth dose increases antibody levels among people aged 60 and over, a separate study suggests that the benefits in disease reduction for younger health workers are only marginal. Other Israeli studies show that a fourth dose improves protection against serious illness, but the added benefit may not last long.

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This is where we must separate the public health perspective from that of the individual patient. From a population health standpoint, I think a fourth dose will not change the trajectory of BA.2 in the United States. About half of those eligible for the third dose have not yet received it, including one in three adults age 65 and older. And, of course, there are those who still haven’t applied a single dose. Getting vaccines to these groups must continue to be the priority of health officials.

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Therefore, the best policy is a permissive allocation. People are not required to take the extra dose, but they can if they want to. In a sense, the decision for additional reinforcement becomes something similar to the continued use of face masks or rapid tests before meetings in closed spaces. There are many Americans who are no longer worried about COVID-19. Those who are vaccinated and boosted may not opt for an additional dose at this time, just as they might choose not to wear a face covering or get tested on a regular basis. This is especially true if they were recently recovered from the omicron variant.

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There are others who remain concerned about the infection of the coronavirus. With the elderly and the clinically frail, who could end up in the hospital with any respiratory infection, I understand the reasoning for wanting to take an extra dose. They want to do everything they can to avoid getting COVID-19. Even if the added protection might not be much stronger than the third dose or last very long, it’s worth it.

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In addition, there are those who received a dose of the Johnson & Johnson vaccine and then an initial booster of an mRNA or Johnson & Johnson vaccine. The CDC is allowing all these people, regardless of age, to receive a second booster dose of mRNA if it has been four months since their last vaccination. I think this extra boost should be viewed in the same way as a fourth dose of an mRNA vaccine: an option for those who want to further reduce risk.

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Are there any disadvantages in applying the additional dose? There is a theoretical possibility that if too many reinforcements are received, the body might not generate as much of a response in the future. A more practical reason is related to the current moment: if the protection is short-lived, it may be better to wait until we know for sure that a big surge is coming. Additionally, Omicron-specific reinforcements are already in development and could be available in the coming months. Some might choose to wait until then, or until there is clear evidence that immunity to serious disease is waning.

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The point is that while it is not at all clear whether people they need a fourth dose, there are those who want and they should be able to access it. The federal government’s position to allow this option signals an important move away from the top-down strategy of orienting public health toward individual decision-making. Going forward, people should be able to use bracing — just as they do face coverings, testing, and treatment — to manage their own risk of COVID-19.

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Opinion | Allowing a second booster dose in the COVID-19 vaccine is a change in the fight against the pandemic

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