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Last month, the CDC recommended that everyone in the U.S. 6 months and older receive an updated Covid vaccine targeting the XBB.1.5 variant. Since then, some notable voices, including Paul Offit, have publicly questioned whether the updated vaccine is needed for those who are not in a high-risk group. He recently wrote, “At this point in the pandemic, it is hard to make a case for vaccinating everyone. Let’s focus on those who are most likely to benefit. Otherwise, we run the risk of further confusing and frustrating the American public.”
Of course there is room for reasonable debate on this important topic. But so far these arguments have been light on specific evidence and are themselves prone to causing confusion (at least if my family and friends are any indication). They downplay both the individual and population-level benefits of vaccination and risk undermining the uptake of the updated Covid vaccine among those who need it most.
Updated COVID vaccinations for all makes sense for eight key reasons:
1.) There is little downside. The vaccines are extremely safe. Skeptics have not been able to cite any real downsides of getting vaccinated. The Covid-19 vaccines are now among the most distributed and safety monitored vaccines in history. The risk of myocarditis for young adult males is even lower upon subsequent doses than the already very small risk following primary series doses, and the risk of adverse cardiac outcomes in this group was many times higher after a Covid infection than after vaccination.
2.) It’s not obvious who is high-risk. Universal recommendations are simpler and likely increase uptake in the most vulnerable. The message that the Covid vaccine is not necessary for some is confusing and will deter many people who would benefit from getting it because they don’t realize they are “high risk.” There’s good reason for that: There is no clearly defined group that has no risk of severe Covid, and it is not easy to know who is at highest risk. Increasing age is the strongest risk factor, but otherwise most people don’t know if they are particularly vulnerable to severe Covid or not. Even age isn’t clear-cut. Many older people I know underestimate their risk based on age alone because they are generally healthy.
Also, the vast majority of the U.S. population has an underlying condition that would qualify under a risk-based recommendation. (For example, more than 70% of adults are overweight or obese). There is evidence that universal recommendations for flu vaccination increased uptake among the most vulnerable groups.
3.) Covid vaccines protect against Covid. I don’t want to get Covid. Even for healthy people who don’t end up in the hospital, Covid can be a nasty illness that can mean days or weeks of missed work and school. I get the flu shot every year to avoid getting really sick, even for a few days. That protection is worth a lot to me, even if it only lasts for the three- to four-month flu season. Neutralizing antibodies increase considerably after vaccination, lowering (but not eliminating) the risk of infection for several months. The updated XBB Covid vaccine is still a good match to circulating variants, meaning this near-term protection may be particularly good right now.
4.) Vaccination likely reduces the risk of long Covid and helps in the recovery for some. Those questioning universal vaccination have been noticeably silent about long Covid. Each Covid-19 infection confers some additional risk of longer-term consequences . Evidence presented at the Advisory Committee on Immunization Practices (ACIP) meeting on the updated vaccine suggested three doses of vaccine were more protective than two doses against long Covid. There is also suggestive evidence that vaccination can alleviate existing long COVID symptoms. While the evidence on long Covid and vaccination is still developing, it’s more than enough to merit consideration in these conversations.
5.) Fewer infections mean less transmission. Less transmission means fewer cases. Fewer cases means fewer serious cases and deaths. That’s math. While COVID vaccines don’t “block” transmission completely as we once hoped, they do reduce the likelihood of transmission. The outspoken voices who say we don’t need universal vaccination are not thinking in terms of population health. If my vaccine protects me from an infection, even in the short term, I can’t pass the virus to others. This means that my vaccine also protects other people, particularly those whose immune systems don’t respond as well to vaccines.
And even if I do get infected, a recent vaccination has been shown to lower the risk of transmission to household contacts. Thinking only about individual-level benefits discounts population-level benefits of broader vaccination like fewer cases overall.
6.) We do need updated vaccines, and lots of people didn’t get the last one. While some argue that the primary Covid vaccine series is sufficient to protect against severe disease and death without additional doses, the evidence suggests otherwise. This year, a large percentage of those hospitalized for Covid-19 had been vaccinated with the primary series but not the bivalent booster, even under age 65 (see figure below). There is evidence that the 2022 bivalent booster, especially in the first few months after receipt, provided additional protection against critical illness and hospitalization, including at the younger ages Offit suggests don’t need another dose. The study Offit cites to argue that not everyone benefited from additional doses of vaccine doesn’t actually say that at all. It looks only at the relative risk of severe disease in people with two doses of the vaccine and different risk factors, finding not surprisingly that the risk was higher among older people and those with co-morbidities.
7.) Kids benefit from the vaccine, too. While kids ages 5-17 have the lowest burden of severe illness, hundreds in this age group have died due to Covid-19 in the U.S. Half of the deaths were in kids with no underlying conditions. The rate of Covid-19 hospitalizations and deaths in kids is higher than pre-vaccine rates for chicken pox and meningitis, vaccine-preventable diseases for which there are universal vaccine recommendations. No parent will be surprised to learn that the majority of the time, children are the source of household COVID transmission.
So besides protection from severe disease — which is a real concern — reducing acute illness in kids means fewer days of missed school for kids and work for parents (not to mention teachers). Babies under 6 months old are not eligible for the vaccine but <1 year olds have the highest pediatric rates of Covid hospitalization and death, so reducing infections in older siblings protects them, too. Take-up of the vaccine in kids overall has been very low, so a universal recommendation for the updated vaccine could help increase overall coverage.
8). The cost-benefit makes sense. I get it: Vaccines are not free to society. While the federal government paid on average around $21 per dose for previous Covid vaccines, it will pay more than three times that this year. Private insurers will pay even more than that. While the vaccine is free to both insured and uninsured individuals, this cost is still real.
But cost-benefit scenarios presented to ACIP showed that universal vaccination was worth the cost under most scenarios. Compared with only vaccinating those older than 65, universal vaccine recommendations were projected to prevent about 200,000 more hospitalizations and 15,000 more deaths over the next two years. These modeling exercises don’t even typically account for things like potential long Covid and lost productivity of parents staying home with sick kids. So, if anything the collective benefits are likely underestimated.
While it’s true that some countries are taking a high-risk only approach to updated vaccines, that by itself doesn’t mean it’s the right choice. In the U.K., some members of Parliament have pushed to expand the scope of the fall Covid vaccine roll-out to alleviate winter pressures on the National Health Service.
The initial launch of the updated Covid vaccines in the U.S. has been bumpy without pandemic-era emergency funding and distribution. Canceled appointments can deter even the most enthusiastic vaccine seekers. Messages from trusted public health experts downplaying the benefits of vaccination will only reduce the incentive to push through logistical hassles.
The bottom line is that everyone can benefit from the updated Covid vaccine. So if you’re on the fence, hop on off of it.
*This article originally appeared in STAT news on October 13, 2023: “Yes, everyone should get an updated Covid Vaccine.”