We should change “fully vaccinated” but it’s hard

I think the evidence has been quite clear for quite some time that we should consider three shots of a Covid vaccine to be “fully vaccinated.”  Many vaccinations are a three shot series and with Covid, that third shot 6 or so months later clearly induces greater immunity than the original series– more antibodies and more diverse antibodies.  Even before Omicron this was clear, but the broader antibody response is even more valuable against Omicron (and future variants).  

I’ve been really glad to see that even if the government is not taking any action, many colleges and universities (including my alma mater, whose Covid response has generally been great).  I asked a friend/colleague  who is plugged in if there was any hope for NCSU, but out health administrators are pathologically dependent on whatever the CDC recommends (and as we’ve long known, they are often weeks/months behind in making recommendations based on the best science).

So, yeah, I’ve really been advocating that we redefine “fully vaccinated” but, as the always-excellent Katherine Wu explains, this is easier said than done.  

Sometime in the very, very near future, that status—and the perks that come with it—could evaporate in an instant for millions of Americans. Medical experts and public-health officials have for weeks been calling for the CDC to alter the definition of fully vaccinated to include another dose. Countries such as Israel have already done it; Anthony Fauci has been gunning for the switch. As he told me this summer, “I bet you any amount of whatever” that three shots, spread out over several months, will ultimately be the “standard regimen for an mRNA vaccine.” Even the CDC told me this week that it “may change [the] definition in the future”—a line it’s never used with me before. For a cautious government agency, that’s kind of a gargantuan leap. A new floor for full vaccination, one that firmly requires what we’re now calling booster shots, is starting to look like a matter of when, not if

A change in definition would almost certainly spur some individual action in the short term; it’s maybe the closest the CDC can get to mandating boosters without, you know, mandating boosters. But it would also invite a whole lot of mess. Millions of people would be bumped back into “partially vaccinated” purgatory. Unvaccinated people would have one more hurdle to clear to achieve CDC-sanctioned status; some could be further disincentivized from getting the necessary shots. If Fauci is correct, the amendment is inevitable, and the risks of a logistics and communications tangle are worth taking now. But some other experts aren’t so sure. “We still don’t know what the optimal vaccination schedule is,” Boghuma Kabisen Titanji, an infectious-disease physician at Emory University, told me.

And there’s still no consensus on what our COVID-19 vaccines are supposed to accomplish in the short or long term. Stamp out severe disease? Aggressively tamp down all infections, so that we can squelch viral spread? In deciding what fully vaccinated meansit would help to know “what outcomes we’re trying to prevent, and why,” Céline Gounder, an infectious-disease physician at Bellevue Hospital Center, in New York, told me. That would dictate our dosing strategies—the what, the when, the how many.

Already, in the year since our shots first rolled out and full vaccination against COVID-19 was first defined, the pandemic landscape has shifted. And in this long fight against a fast-moving, fast-morphing virus, we may never actually, truly be fully vaccinated at all. Updating the definition of fully vaccinated is a strong move—hence the push for it at all. But it’s also a reminder of the power of waiting until we’re more sure of what we want our shots to do.

On that last point, oh, I’m sure what we want the shots to do– prevent disease! That’s actually what we seemingly what most vaccines to do is prevent disease, not just severe disease.  

None of this waffling is, to be clear, an indictment of boosters. By this point in the pandemic, it’s quite clear that adding on more shots can come with big benefits, especially now. Months have passed since many people got their shots, leaving antibody levels relatively low. And the heavily mutated Omicron can hopscotch over several of the antibodies that are left, taking hold more easily in vaccinated bodies compared with its predecessors, and perhaps transmitting more rapidly out of them. But a booster’s bump can skyrocket both the quantity and quality of frontline immune defenses, and restore much of the body’s ability to pin the coronavirus in place. Early data suggest that while two doses of an mRNA vaccine deliver kind of meh protection against Omicron infection, tacking on another dose brings the body back to a Delta-like benchmark. Omicron will still spread within vaccinated bodies, and among them. But it will do so less often with a booster. At this point, “I don’t think we can meaningfully interrupt transmission without three doses,” Saad Omer, a Yale epidemiologist, told me. Our viral opponent has clearly upped its offense, and boosters—a bolstering of defense—have never made more sense.

Looping boosters into “full vaccination,” then, could clinch the importance of these shots. “We’ve hit a tipping point,” Jason Schwartz, a vaccine-policy expert at Yale, told me. It’s become essential to “encourage and promote boosters,” and sticking stubbornly to a now-obsolete definition of fully vaccinated could undermine that effort.

A modification wouldn’t be without precedent. The measles/mumps/rubella vaccine first debuted as a single shot, but it became a double-doser in 1989 to better contain outbreaks; the chicken-pox vaccine underwent a similar tweak in 2006…

A definitional conversion for fully vaccinated would also create logistical nightmares for freshly instated mandates that rely on the current definition—one dose of J&J, two of mRNA. In practice, an update to fully vaccinated could completely rejigger who is and isn’t compliant; workers who only just met a two-dose mandate would have to await a third shot at the six-month mark. “You already have a lot of resistance,” Gounder said. Faced with new requirements, some employers might try to do away with mandates entirely; employees might choose to call it quits.

The prospect of three required doses could also raise a barrier for people still trying to decide whether they want to get any COVID-19 shots at all. Right now, a one- or two-dose shot means waiting two to six weeks to hit full vaccination. A three-doser could balloon that to eight months, with potentially three rounds of side effectsOne of the best ways to protect the world is for unvaccinated people to get vaccinated; we could quickly find ourselves in trouble if third doses get pushed at the cost of firsts. Ideally, we’d bring the entire world to three injections—perhaps more if needed. But partial vaccination is still better than none. And the more doses we buy up and urge onto the residents of wealthier countries, the harder it becomes for people around the world to get their initial series, giving the virus more places and chances to transform itself into something even more troublesome.

Well, damn, that’s complicated.  I still think potential benefits of a re-definition outweigh potential costs, but it’s clear there’s potentially very real costs.  That said, this approach sounds great:

With all of these factors at play, experts like Grace Lee, a Stanford pediatrician and the chair of the CDC’s Advisory Committee on Immunization Practices, thinks we might be better off shifting the conversation entirely—asking whether people are “up-to-date” on their shots, rather than whether they’re fully vaccinated. Whereas fully vaccinated implies a sort of finality, and has, to some, even become shorthand for fully protectedup-to-date is more flexible and forgiving. The phrase, which is already used among health professionals when discussing vaccines, might leave more room for individual tailoring, and it accommodates the unpredictability of our circumstances. Up-to-date is also a little more agnostic on the primary-versus-booster distinction. And asking “Did you get your shot this year?” rather than “Are you fully vaccinated?” could be an especially useful framework, Lee told me, if we end up having to retool and readminister our vaccines somewhat regularly, much like we do with vaccines for the seasonal flu.

All that said, whatever we call it, we absolutely should prioritize getting that third shot in as many Americans as possible.  And part of that, presumably, is how we define “fully vaccinated.”  

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