Second COVID Booster: Get it Now, or Wait Until Fall?

The 60-year-old woman with several health issues took her octogenarian mother to her primary care doctor this spring. The subject of whether they should update their COVID immunizations came up.

They each had received two primary doses and one booster, and wondered whether getting the second booster was worth it.

The physician recommended waiting. Cases were ebbing at the time, and there might be a more potent booster available later in the year. But most of all, the doctor told them, if they waited until August or September, they could be better protected against an anticipated winter surge.

So that’s what they did, leaving themselves unprotected against new and highly transmissible variants now surging in their community through the summer, but potentially better shielding them closer to the holidays.

But not everyone thinks such clinical guidance was the best.

“In my view, this would be very bad advice,” said Robert Schooley, MD, an infectious disease expert at the University of California San Diego, who has been a member of FDA vaccine advisory committees.

BA.5 is now the dominant variant in the U.S., and it has drifted so much that protection from the first vaccine doses are now less effective, Schooley said: “It is clear that those boosted once last year have seen substantial reductions in immunity since their vaccinations last year.”

Likelihood of Ending up Dead

People who are vulnerable, including older people and those with significant health issues, “are at substantial risk of becoming infected over the next eight to 12 weeks given the extremely high contagiousness of these strains and the broad community spread,” Schooley added. “Being current on vaccination is the best way to reduce the likelihood of ending up in the hospital or dead.”

An April study in Nature with 563,465 participants ages 60 to 100 who had received their first booster more than four months previously found substantial reductions in hospitalizations and deaths among those who received a second booster compared with those who had received only their first booster.

Only 270 of the 328,597 people who received a second booster were hospitalized during the 40-day study period, compared with 550 of the 234,868 who did not get a second booster. Additionally, 92 of those who received the second booster during the study period died due to COVID-19 compared with 232 who had received just one dose. The likelihood of death increased with age.

At a White House COVID-19 Response Team briefing on Tuesday, team coordinator Ashish Jha, MD, offered guidance: “In terms of what to recommend to people right now, if you’re over 50 and if you’ve not gotten a shot in 2022, first of all, getting one now protects you for the rest of the summer into the fall. Second, it does not preclude you from being able to get a bivalent vaccine in the fall. So that’s why I think for me, it’s a very, very clear recommendation.”

Some clinicians told MedPage Today that if their patients express any reluctance to get all of their booster shots, he refers them for blood work to see whether and how much protection from prior doses may have waned. San Diego internist Paul Speckart, MD, says that armed with declining numbers, he can make a more persuasive case.

It’s not uncommon to hear physicians take a more relaxed attitude, Speckart said, although he disagrees that delaying a booster shot was wise advice to give a patient.

One eligible San Diego man said he was deterred from getting the booster after reviewing county statistics showing more cases and a slightly higher number of hospitalizations in people who were boosted than people who were not. However, the county charts are not adjusted for the likelihood that many people who got boosted were older with more comorbidities and had a higher risk of being hospitalized.

For those still deciding, the CDC’s booster calculator provides guidance for anyone unsure about their eligibility. Generally speaking, for people age 60 and older, a first booster is recommended for those who received primary immunization more than 5 months previously, and a second booster is recommended for those who received their first booster more than 4 months ago.

James Grisolia, MD, a San Diego neurologist, described it as a physician’s dilemma. “While we were between surges, I would have given similar advice (to wait before getting the second booster) but as of several weeks ago, it was obvious we were going into another surge. I began encouraging older folks to get their second booster.”

It’s a dilemma, he said, because it was reasonable before the latest surge to give patients protection that would be most effective this fall and through the winter, and that would require delaying the dose until August.

Besides, he said, “they only announced they were working on an Omicron-flavored booster in the last few weeks, and it’s still speculative that Moderna or Pfizer will find coverage for the variants we will actually have then.”

Relaxed Attitude

Grisolia said what he most worries about are the people “who just won’t get vaxxed, period.”

This reporter has also noticed that even in healthcare settings, there is a relaxed attitude about masking and other precautions. In the last several weeks, some clinical settings have removed the signs and yellow ribbons on chairs that prohibited people from sitting less than 6 feet apart.

And healthcare staff at a San Diego physician’s office and a physical therapy practice had to be reminded on the proper way to wear a mask, covering both the mouth and the nose, even though most were wearing cloth masks instead of N95s or surgical masks.

Grisolia agreed. “It’s certainly right that folks are psychologically ‘over it’ and not being careful,” even as hospitalizations are creeping upward, and many area clinical staff have been calling in sick, he said.

Meanwhile, in anticipation of new demand for vaccines this fall, the Biden administration has agreed to purchase more than 100 million doses of Pfizer’s COVID-19 vaccine. Last month, an FDA advisory committee voted 19 to 2 to recommend that future COVID-19 vaccine boosters include an Omicron-specific target, though how soon that will happen remains unclear.

Schooley noted that while there are vaccines promised for fall, “the key word is ‘promised.’ They have not yet been reviewed by the FDA or the CDC and still need to be produced at industrial scale.”

He noted delays in “promised” vaccines for children and that “there is no guarantee that these vaccines will be ready when projected. Furthermore, we know from past experience that if they are suddenly available on, for example October 1, it takes many weeks to work through the entire population and people hoping to be vaccinated as soon as the vaccines are approved might find themselves still waiting at Thanksgiving.”

The 60-year-old woman who lives with her mother said that based on increasing case counts, she has now reconsidered, and that both are scheduled to receive their second boosters soon.

Joyce Frieden contributed to this report.