Narrowing the vaccine gap as boosters begin for people over 50

The Food and Drug Administration this week authorized a second booster for individuals 50 and older. Although some people over the age of 50 are mulling whether and how soon to get their fourth jab, a significant vaccine gap exists within this group which needs to be addressed. There are 118.5 million Americans over the age of 50; 18.4 million (15%) of these individuals are not fully vaccinated and 59 million (50%) have not received their first booster.

Closing that gap will be a challenge, especially given that the Health Resources and Services Administration on March 22 stopped accepting claims for Covid testing for the uninsured and on April 6 will do the same for vaccines. Millions of uninsured patients will no longer have the protection vaccination confers, and will be denied access to free Covid tests and treatments. Eligible patients, including those with fragile medical conditions in search of monoclonal antibodies, will struggle to access outpatient treatment, leading to a likely rise in hospitalizations. Without swift approval from Congress for emergency Covid-19 funds, the costs of inaction will inevitably lead to dire consequences for the most vulnerable. The $10 billion Senate compromise to procure therapeutics and vaccinations — roughly half of the $22.5 billion requested by the White House in mid-March — is insufficient, and we are all at risk if the U.S. can not deploy critical tools, including  surveillance and the global vaccination campaign.

Asia and Europe are experiencing a rise in cases, and certain European countries are reporting an uptick in hospitalizations. The BA.2 variant, combined with the recent lifting of restrictions and possible waning of immunity, has caused the viral transmission to accelerate. In the U.S., which has typically experienced surges three weeks behind Europe, 49% of sites sampled by the Centers for Disease Control and Prevention’s National Wastewater Surveillance System have seen increases over the past few weeks. The forecast is uncertain, but because better tools and surveillance are available than during previous waves, the best defense is preparation for this variant.

Many Americans are not up-to-date with their Covid-19 vaccine. A recent New England Journal of Medicine paper shows that those infected with the original Omicron strain and not previously vaccinated had antibodies that proved to be largely ineffective at protecting against other viral strains. Communication with the public should emphasize the importance of vaccines, how they protect the vulnerable from severe disease, long Covid, and death, and how their protection wanes over time. All Americans need to have reliable access to vaccines, including the millions of Americans who have contracted Omicron.

Vaccines and boosters have proven to be highly protective against severe outcomes. A recent CDC study found that three doses of an mRNA vaccine were 94% effective against requiring ventilation or death, even during the Omicron surge. During Omicron, two doses were 79% effective against the same outcomes. Without congressional approval for new funds, we will face a cliff in discovery and development of promising new vaccine candidates. This includes next-generation vaccines to broaden protection against future variants, and extend the duration of protection and the shelf life of the vaccine to decrease costs. All Americans deserve to benefit from the protection of these lifesaving vaccines.

Congress must pass the bill to ensure states can lead and undertake three important steps.

First, efforts must continue to reach the unvaccinated. The pace of new vaccinations is among the lowest since the rollout began. Yet there is still some untapped potential in reaching the unvaccinated. According to a recent Economist/YouGov poll, 31% of those who say they are unvaccinated express interest in receiving a vaccine in the future, including 32% of Americans with lower household incomes. Increasing vaccine access through mobile and school clinics can help people start their vaccination series.

Second, the pace of booster administration must accelerate. Boosters help maintain protection against severe disease and will blunt the effects of a BA.2 surge. Yet only half of those eligible have received a booster. Particularly of concern is low booster uptake in older age groups — 40% (22 million) of individuals over the age of 65 have not been boosted. In nursing homes, only 67% of residents and 41% of staff have been boosted. There’s much that needs to be done to protect those most at risk for severe outcomes. Proactive outreach includes calls, text messages and scheduling appointments for Medicaid enrollees. Primary care physicians should stress the importance of remaining fully protected and offer boosters during appointments. Rather than leaving the scheduling and administration of booster doses up to nursing homes, health departments should schedule emergency nursing home booster clinics for those facilities with low rates.

Third, with this phase of vaccinations, investment in the equitable distribution and delivery of all tools should be ramped up. The Omicron wave took an unequal toll on many Americans. Americans with lower household incomes were more likely to report having to miss work during the Omicron surge, which also resulted in economic disruption. In many areas, child vaccination rates are stratified along income lines. Although great strides were made to reduce inequities last spring, the booster rollout has perpetuated lower vaccination rates in Black and Hispanic Americans. Improving access to and uptake of vaccine doses in low-income and minority populations should be a top priority.

These three steps will all require federal resources. Failure to provide those resources could result in a reversal of the progress we have made so far. Without further funding, 28 million uninsured Americans, who already have lower vaccination rates, will have fewer options for vaccination. Increasing vaccination rates, specifically among those more vulnerable to severe outcomes, is a key strategy to help abate BA.2’s effects and minimize the potential disruption to health services for all.

Rebecca Weintraub is the faculty director of Harvard’s Global Health Delivery Project, and Better Evidence at Ariadne Labs and an associate physician at Brigham and Women’s Hospital. Benjy Renton is an analyst at Ariadne Labs focusing on vaccine delivery solutions. David C. Grabowski is a professor of health care policy at Harvard Medical School in Boston.