Booster shots alone won’t protect immunocompromised people from Covid-19

Covid-19 taught me something about second chances: In March 2020, I fought the virus and won. Barely.

But my gratitude for the chance to live, to continue to be a husband and father, and to work in the hospital again doesn’t translate into an optimistic perspective on the latest deadly phase of the pandemic. Collectively, we may be running out of second chances.

Some herald a booster shot intended to protect patients with weakened and/or suppressed immune systems as a second chance, with the Biden administration likely to expand that in mid-September to all Americans who received an mRNA vaccine (Moderna or Pfizer/BioNTech).

The Centers for Disease Control and Prevention now advises a third dose of an mRNA vaccine for people who are moderately to severely immunocompromised who received those vaccines. The Food and Drug Administration (FDA) has amended the emergency use authorizations (EUAs) for administering an additional dose to those individuals.

A March 2021 report in JAMA showed that only about 17% of immunocompromised people built sufficient levels of protection against the virus after the first dose of an mRNA vaccine. That increased to about 56% after the second injection. It’s still too early to know if, or how much, it will increase after a booster shot.

Fully vaccinated immunosuppressed individuals have accounted for 40% to 44% of breakthrough infections requiring hospitalization. They’re also more likely to transmit the virus to household contacts.

In the United States, about 3% of adults are immunocompromised: transplant recipients, people with cancer, those with HIV, and individuals who take immunosuppressants. Transplant recipients alone are more likely to have an 82-fold higher risk of breakthrough infection and a 485-fold higher risk of breakthrough infection leading to hospitalization and death.

So the CDC’s statement that immunocompromised patients, are “especially vulnerable to Covid-19 because they are more at risk of serious, prolonged illness” felt to me like an understatement.

There’s hope in preliminary results from a study in Israel which indicates that a booster shot may double the rate of certain transplant recipients who developed antibodies against SARS-CoV-2, the virus that causes Covid-19 — if they received an mRNA vaccine. To date, there aren’t studies of immunocompromised patients who received the Johnson & Johnson vaccine, rendering them ineligible for booster shots at this time.

I welcome the chance that booster shots bring. It’s feasible that we’d be able to vaccinate this small population in just a few weeks — but it’s not a foolproof strategy.

“These patients should be counseled to maintain precautions to help prevent Covid-19,” the FDA says. That means washing hands, wearing masks in public indoor settings in areas of substantial or high transmission, social distancing, and limiting indoor interactions. People who are in close contact with immunocompromised individuals should also get vaccinated to provide increased protection to their loved ones.

This is where I lose sleep. The health of immunocompromised people depends on far more than a Covid-19 booster shot.

What they —and the rest of us — need is more people in the general population to be vaccinated, and quickly, because the Delta variant is more transmissible and severe than the earlier predominant strains of SARS-CoV-2 and the virus could outsmart current vaccines and mutate — again. We need effective treatments for people with Covid-19 because cases are on the rise, and that includes children, who have been filling hospital beds as they come down with other viruses such as respiratory syncytial virus, flu and enterovirus. We need vaccines approved for kids 11 and under as we approach another school year.

Normalcy is out of reach until these things happen.

Boosters are an important step, and one that most Americans will soon be advised to take. But their effectiveness depends on all of us to take responsibility for ourselves and each other. As I work with medical systems across New York to find more hospital beds for kids, I worry that too many people don’t understand the stakes and are unwilling to face these truths.

I’m grateful for second chances, but fear we may be running out of them.

Matthew Harris is a physician who specializes in pediatric emergency medicine, medical director of the Covid-19 vaccination program at Northwell Health, and assistant professor of pediatrics and emergency medicine at the Zucker School of Medicine in Hempstead, New York.