To boost or not to boost

Should that be the question?

37 min ago

The reluctance for Americans to get a booster shot has been striking. The United States currently ranks 73rd among countries for its uptake of boosters at 33% of its population. All peer, rich countries around the world are at least double that rate. Countries ranking above the US now include Rwanda, Uzbekistan, Iran, Honduras, and Azerbaijan. Seemingly, you’d have to work very hard to show up this poorly as the country that first validated the vaccines, manufactures them, and has had such a surfeit supply that it has >50 million shots it can’t get anyone to take. Nonetheless, it has maintained optimism and purchased 171 million new Omicron BA.5 variant bivalent shots.

So why is the rate of immunization so low in the United States? It is not about science. Eric Topol M.D. is a well-respected authority. Precision Medicine is touting how we need another booster shot. It is also not a political issue. Americans no longer have faith in government recommendations. During the last several decades the U.S. government made many poor choices, including severe restrictions, social distancing, personal protective equipment, and shutting down the economy, as well as promoting major wars in Iraq and Afghanistan.

In other countries that may be less developed, people accept government decisions, not knowing the details about vaccines. %10%1

Our current rate of inflation (about 10%) is largely due to the stimulus packages. That was money we printed, for which there is no real backing.

On the one hand, according to Topol, there is incontrovertible evidence for the benefit of a booster.

Very strong evidence supporting boosters dates back to October 2021, when the results of the only large (~10,000 participants) (1st) booster randomized trial were released and later published, with a 95% reduction of symptomatic infections across all age groups, through the Delta wave, durable at that level for at least 4 months. There were no safety concerns or myocarditis. The efficacy level was fully restored to the original randomized trial (95%) reports in November 2020.

The right question

Boosters provide substantive and unequivocal benefits for protection from severe Covid and are likely to help, to at less some degree, reduce Long Covid, and certainly have some early (2 months) effects for reducing infection and transmission. We don’t know yet if the BA.5 bivalent booster is any better than the BA.1 or the original booster. Based on the evolution of the virus through Omicron and its subvariants, it appears unlikely the new vaccine will have a major or important impact on reducing infection or transmission (we got a hint of that from the new BA.1 NEJM study above). There’s ample evidence from multiple studies that mucosal IgA antibodies are what will be needed to help block infections and transmission, such as this NEJM new report with 60-80% reduction of breakthrough infections (and reduced viral load, higher Ct, Tables below) as a function of mucosal IgA antibodies, not related to IgG antibodies. While they were formed in some health care workers as a response to vaccination and or infection, there is a way to induce them via nasal or oral vaccines. The durability of this effect isn’t yet known, but it would be far easier to take a nasal spray repetitively, with the expectation of much fewer side effects, than shots. Certainly encouraging data from CanSino’s newly approved inhaled vaccine vs Omicron is a solid precursor for the many programs that are in advanced clinical trials.

The right question is about the future. We can’t go on getting boosters every 4 to 6 months and the premise of an “annual” shot is that the virus exhibits seasonality like flu, which certainly isn’t the case.

Economics play a large role in who gets vaccines. In poor countries, it is often not available. In developed countries including the U.S. that is not a limiting factor.

The truth lies somewhere in the statistics which can be read below.