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To boost or not to boost, that is the question

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The entire issue of COVID-19 vaccination has been subject to vigorous public debate. There have been disagreements, polarized opinions, misinformation, and fears about threats to individual freedom. There also have been concerns about preventable deaths due to low vaccination rates that, in some cases, have fueled new variants, which can threaten the health of Americans. 

The wide-ranging personal preferences about vaccination include those who clamor to get as many doses of vaccine as quickly as possible, while others view vaccination as a fate worse than death. With the approval of multiple boosters for different age groups at varying intervals, the vaccination conversation becomes even more confusing and complicated.

Last November, following federal guidance, the Missouri Department of Health and Senior Services (DHSS) said all adults aged 18 years and older who received the Pfizer-BioNTech or Moderna vaccine could receive a booster dose at least six months after the primary two-dose series. In January, that interval was updated to five months. 

On March 30, Missouri DHSS said a second booster dose of the Pfizer COVID-19 vaccine may be administered to all individuals 50 years and older and moderately to severely immune-compromised individuals 12 years and older at least four months after their initial booster dose.

We sat down with Dr. Philip Fracica, Bothwell Regional Health Center’s chief medical officer, to talk about the vaccines and immunity, research and data that led to decisions to recommend boosters and who boosters most benefit.

“I think one of the big issues involves what we intend to accomplish with vaccination,” Fracica said. “Is the goal to avoid hospitalization, serious illness and death? Or is the goal to prevent every possible infection, including breakthrough infections, reinfections and asymptomatic infections? Clarity about the goal is crucially important because the level of immunity necessary to prevent death or serious illness is much lower than the level of immunity necessary to extinguish any infection whatsoever.”

Fracica said there is the added issue that every patient is unique and will have an individual pattern of antibody rise and fall, with some people having higher and longer-lasting post-vaccination immunity, while others develop lower levels of immunity that will fade much more quickly.  

“To some extent, we can overcome this uncertainty about individual response by using research knowledge to identify individuals who are likely to have a weaker immune response and make different booster recommendations for that group,” he said. “One of the key data sources used by public health professionals is information from individuals who received the vaccine much earlier than the U.S. general public. Much of this data comes from study individuals who volunteered for the earliest clinical research trials of the COVID-19 vaccine, as well as data from other countries, notably Israel, which initiated wide-scale public vaccination months before the United States.”

By observing the patterns of post-vaccination immunity, including how quickly antibody levels drop and comparing that with outcome data about serious life-threatening infections as well as milder breakthroughs and reinfection, Fracica said it’s provided enough scientific evidence to make a case for the second booster in certain age groups. 

“Israeli data showed dropping antibody levels in young, healthy individuals who had received full vaccination and a first booster,” he said. “However, in the young and healthy individuals studied, the drop in antibody levels did not seem to result in any increased risk of infection or serious illness. Data from another Israeli study looked at individuals aged 60 and above. Among this older population, 91% protection from serious illness occurred following the first booster and this protection dropped to 78% four months after the initial booster. Other research indicated that for people aged 60 and above, the second booster reduced the risk of death from COVID by 78%.”

So, what should the average individual do?

“People who are older and more concerned about becoming infected should take advantage of this opportunity to ‘top off’ antibody protection and benefit from a reduced chance of death or serious illness,” Fracica said. “Older individuals who are weaker and frailer with serious health problems like diabetes, obesity and chronic heart and lung disease may benefit even more from a booster.”

Fracica said people with these types of health issues should also not overlook the continued added benefit they can get with social distancing measures, including avoiding enclosed indoor spaces packed with many people and the use of masks to reduce exposure risk. 

On the flip side, people in good health may not need to rush to get a second booster.

“Individuals who are 50 and above, in generally good health and not particularly concerned about becoming infected could reasonably choose to wait at this time,” he said. “That said, any specific personal health circumstances should be discussed with your physician.”

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