C.D.C. Panel Meets on Who Gets Booster Shots After F.D.A. Decision

Scientific advisers to the C.D.C. also recommended the coronavirus vaccine boosters for those with certain medical conditions, but excluded those at risk because of their jobs.,

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A C.D.C. panel recommends Pfizer-BioNTech boosters for many Americans, but not health workers.

A dose of the Pfizer-BioNTech vaccine was prepared at a clinic in Reading, Pa., earlier this month. Credit…Matt Rourke/Associated Press

Sept. 23, 2021Updated 5:41 p.m. ET

A day after federal regulators authorized Pfizer-BioNTech coronavirus booster shots for Americans at risk of severe Covid-19, scientific advisers to the Centers for Disease Control and Prevention on Thursday recommended the booster shots for a wide swath of the country, including tens of millions of older Americans and those with certain medical conditions. But the panel excluded those at risk because of their jobs.

The Food and Drug Administration on Wednesday authorized boosters for older and high-risk recipients of the Pfizer vaccine at least six months after their second injection, as well as for people whose jobs leave them exposed to the virus, including health workers, teachers and grocery workers.

The C.D.C.’s science advisers unanimously supported the booster for adults older than 65 and for residents of long-term care facilities. And 13 of the committee’s 15 members also endorsed the shots for people aged 50 to 64 years with medical conditions that leave them at risk for severe Covid-19.

Some members urged the committee to include some flexibility for individuals under 50 to obtain boosters, based on their individual benefit and risk. But others pointed — with considerable frustration — to a lack of data supporting the need in the other groups.

After a protracted discussion, a majority of the panel recommended the boosters for adults aged 18 to 49 years with underlying medical conditions, based on their individual benefit and risk.

They disagreed most on whether some people in some occupations or settings are at heightened risk. By a close vote of nine to six, they voted to exclude people at risk because of their occupations. This measure would have applied to health care workers, teachers and other workers who do not meet the other criteria.

The Pfizer-BioNTech vaccine is approved for anyone over age 16, but the F.D.A.’s authorization for the booster includes only those over age 18.

Dr. Rochelle Walensky, the C.D.C. director, is expected to endorse the recommendations of its scientific advisers on Thursday or Friday, and people who meet the criteria could start getting the shots immediately afterward.

The number of Americans who will qualify includes only those who already received two doses of the Pfizer-BioNTech vaccine. The panel was not asked to judge whether people who received the Moderna and Johnson & Johnson vaccines should receive booster shots, which have not been authorized by the F.D.A.

Several experts nevertheless supported a mix-and-match strategy, and signaled that they would revisit the issue as new data emerge.

State health departments generally follow the recommendations of the C.D.C.’s Advisory Committee on Immunization Practices.

And anyone who wants a booster may simply be able to walk into a pharmacy and ask for one — many Americans already did so before the F.D.A.’s authorization, typically by finding a cooperative pharmacist or pretending to be unvaccinated.

The C.D.C. panel’s guidance followed weeks of internal disagreement and public debate among American health officials and advisers. In mid-August, President Biden announced plans for a booster rollout, but regulators significantly slowed the proposed timeline.

And public health experts criticized what they said were confusing public messages from the Biden administration, all the more notable because the F.D.A. does not have a permanent leader. Its acting commissioner, Janet Woodcock, said on Wednesday that the authorization would allow for booster doses “in certain populations such as health care workers, teachers and day care staff, grocery workers and those in homeless shelters or prisons, among others.”

But some members of the C.D.C. panel said there was little evidence to suggest that vaccinated teachers, and even health care workers, are at risk of repeated exposure to the virus.

Millions of Americans who received the Moderna and Johnson & Johnson vaccines are still waiting to learn whether they, too, can get boosters. The F.D.A. is expected to take up the question in short order.

During a two-day meeting culminating on Thursday, the C.D.C.’s advisory panel wrestled with the public’s expectations for Covid vaccines, the safety of third doses and how a booster program would affect nursing home residents.

The advisers also grappled with the lack of clarity on the goal of the vaccines: Is it to prevent all infections, or only to forestall severe illness and hospitalization? Many suggested it should be the latter, and that thwarting all infections was a foolhardy goal.

Several members of the committee pointedly questioned why federal health agencies were focusing on booster shots for Pfizer recipients to begin with, given the higher risks facing the unvaccinated.

“We may move the needle a little bit by giving a booster dose to people,” said Dr. Helen Talbot, an associate professor of medicine at Vanderbilt University. But, she added, “the hospitals are full because people are not vaccinated.”

Pfizer scientists had argued to the committee that waning antibody levels in people who had received the shot indicated that their immunity was dropping.

Understand Vaccine and Mask Mandates in the U.S.

Vaccine rules. On Aug. 23, the Food and Drug Administration granted full approval to Pfizer-BioNTech’s coronavirus vaccine for people 16 and up, paving the way for an increase in mandates in both the public and private sectors. Private companies have been increasingly mandating vaccines for employees. Such mandates are legally allowed and have been upheld in court challenges.Mask rules. The Centers for Disease Control and Prevention in July recommended that all Americans, regardless of vaccination status, wear masks in indoor public places within areas experiencing outbreaks, a reversal of the guidance it offered in May. See where the C.D.C. guidance would apply, and where states have instituted their own mask policies. The battle over masks has become contentious in some states, with some local leaders defying state bans.College and universities. More than 400 colleges and universities are requiring students to be vaccinated against Covid-19. Almost all are in states that voted for President Biden.Schools. Both California and New York City have introduced vaccine mandates for education staff. A survey released in August found that many American parents of school-age children are opposed to mandated vaccines for students, but were more supportive of mask mandates for students, teachers and staff members who do not have their shots. Hospitals and medical centers. Many hospitals and major health systems are requiring employees to get a Covid-19 vaccine, citing rising caseloads fueled by the Delta variant and stubbornly low vaccination rates in their communities, even within their work force.New York City. Proof of vaccination is required of workers and customers for indoor dining, gyms, performances and other indoor situations, although enforcement does not begin until Sept. 13. Teachers and other education workers in the city’s vast school system will need to have at least one vaccine dose by Sept. 27, without the option of weekly testing. City hospital workers must also get a vaccine or be subjected to weekly testing. Similar rules are in place for New York State employees.At the federal level. The Pentagon announced that it would seek to make coronavirus vaccinations mandatory for the country’s 1.3 million active-duty troops “no later” than the middle of September. President Biden announced that all civilian federal employees would have to be vaccinated against the coronavirus or submit to regular testing, social distancing, mask requirements and restrictions on most travel.

And on Thursday, C.D.C. scientists presented models indicating that, if booster doses were to slightly increase people’s protection against hospitalization, the additional shots could prevent more than 2,000 hospitalizations for every million doses given.

But it is not at all clear how long any additional protection from a booster would last.

Some committee members doubted the wisdom of looking only at antibody levels to gauge immunity. The antibodies needed to prevent infection may naturally wane a few weeks to months after the injection, but the immune cells that prevent illness from progressing — but are harder to measure — remain stable many months after the second dose, according to data presented by one C.D.C. scientist.

Boosters can reduce infections in nursing home residents, who are among those at highest risk. Even so, cases in nursing homes will persist when community transmission is high, according to a modeling study presented at the meeting.

Scientists who presented data to the advisers noted that while a third dose would undoubtedly amp up antibody levels, it’s unclear how long those elevated levels would last, whether they translate to meaningful extra protection against severe disease, and whether they can significantly decrease transmission of the virus.

They also noted the paucity of safety data, especially among younger people.

The advisers also wrestled with the practicalities of endorsing a booster shot of Pfizer’s vaccine, but not of Moderna or Johnson & Johnson’s. Recipients of those vaccines may rightly feel resentful of being asked to wait if the evidence suggests they need boosters, they noted.

“I just don’t understand how, later this afternoon, we can say to people 65 and older, ‘You’re at risk for severe disease and death, but only half of you can protect yourselves right now,'” said Dr. Sarah Long, a pediatrician and infectious diseases expert at Drexel University College of Medicine in Pennsylvania.

“It might be the right thing to do,” she said. “It just doesn’t sounds like a good public health policy.”

Some experts seemed to suggest on Wednesday that it might be better to hold off on recommending any booster shots until recipients of all three vaccines could qualify for them.

Moderna’s authorization may arrive in a few days to weeks. The company has applied for authorization of a booster carrying half the dosage given in the first two shots, which has delayed the F.D.A.’s deliberations.

Federal regulators have indicated that there was insufficient evidence for mixing first shots of the Moderna vaccine with a Pfizer booster, or vice versa.

Some global health experts have criticized the Biden administration for pushing booster shots when much of the world has yet to receive a first dose. But analysts also noted that even if the United States gives booster shots, there would be considerable excess vaccine supply this year, and urged the government to begin sending those doses abroad.

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