Understanding the bigger public health debate on COVID-19 booster vaccines

Paul Offit

Paul Offit, M.D., speaks at CSICON in 2018. Photo by Karl Withakay (CC BY-SA 4.0)

When covering public health policy decision-making, it’s not uncommon for experts to agree on the big picture but disagree on the details — how to get there. 

That’s particularly been the case when it comes to deciding which populations should be urged to receive COVID-19 booster shots. When reporters interview experts about the booster shots, it’s critical that they clarify whether the expert’s comments represent only their own opinion, an overall consensus or that of one faction within a greater quasi-consensus.

Not clarifying the bigger picture for audiences can cause confusion and deny them the opportunity to understand different perspectives that are both science-based.

For example, recent stories have frequently quoted infectious disease physician and vaccine expert Paul Offit, M.D.,who has been a go-to source on vaccines in general for decades. But Offit’s perspectives on the new booster vaccines represent one half of an ongoing public health discussion regarding how vaccines should be recommended — a debate whose context can help the public better understand that public health decisions, even when based on data, are messy and can have multiple “right answers.” 

Offit believes that boosters should be recommended for those at highest risk for severe disease, partly because it’s what other countries are doing and he believes it more efficiently allocates energy in encouraging booster uptake among those who need them most. That includes people over the age of 75, pregnant people and immune-compromised people, as recent coverage has quoted him. But it also includes “anybody of any age who has comorbidities that put them at high risk of heart, lung, kidney, liver or neurological disease, anyone with obesity or diabetes, should get a dose of the [booster] vaccine,” Offit told me. 

“That doesn’t mean other people can’t choose to get it,” including people who live in the home of someone who’s immune-compromised or otherwise high risk, or who works among high-risk people, he added. “Those are other reasons to get a vaccine,” he said. “But if the goal of this vaccine is to prevent severe disease, which is our goal, then the question becomes who’s most likely to get severe disease.” Recommending it to everyone, Offit says, misses the mark. “I think the country didn’t buy into that [last time], as the uptake was very low” (around 20.5%), he said. “But more importantly, we lost the capacity to message who really benefits most.” 

Offit’s opinion is valid, and he has the expertise to make it. But it’s not the only opinion on this issue among public health and infectious disease experts, and it doesn’t necessarily represent a majority consensus. 

“There has been a very complete, thorough, friendly debate” regarding how to recommend boosters, William Schaffner, M.D., a professor of infectious disease and health policy at Vanderbilt University Medical Center, told me. Offit articulated one position — to look at who has the most severe disease and issue risk-based recommendations for those groups. 

The other, which Schaffner advocates, is to continue recommending the vaccine routinely for the majority of the population ages 6 months and older. One advantage to that approach is continuity and the fact that it’s “analogous” to flu shot recommendations, he said. Another is that “it’s very simple to communicate,” which is “absolutely critical” in public health messaging, he said. Finally, routine, universal recommendations “apply without question to everyone, and that is a greater assurance of equity,” which the CDC’s Advisory Committee on Immunization Practices takes very seriously, Schaffner said.

“We’ve been moving in general away from risk-based recommendations for adults in vaccines and toward more universal recommendations, because when you make a universal recommendation, you tend to get more people who are in risk groups in your net,” Schaffner said.  

Kevin Ault, M.D., chair of the Western Michigan University School of Medicine’s OB-GYN department and who recently completed service on the CDC Committee, agreed that “universal recommendations tend to do better as far as uptake as opposed to risk-based recommendations,” he told me, noting decades of evidence on this for the flu shot and hepatitis B vaccine. 

Although the Committee’s votes have tended to “wax and wane” between these two schools of thought, “in the recent past, I think there’s been a trend towards more universal recommendations because they’re easier to implement,” Ault said. It’s not realistic, he explained, to expect a provider or a patient to parse out who should and shouldn’t get a vaccine during an office visit, especially when the recommendations involve multiple different risk groups. “There’s infinite possibilities of people who might want to be vaccinated because of their job description or personal circumstances or uncommon health things that didn’t fit under the clinical trials or guidelines,” Ault said.

Schaffner also emphasized that, “in public health, there is frequently not a single right way. There are choices you have to make.” This is a reality that health journalists haven’t adequately communicated since the earliest days of the pandemic, but there’s plenty of time to change that by providing better context for these discussions. 

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