America Created Its Own Booster Problems
Months of confusing messaging, piled onto existing inequities, kneecapped America’s booster campaign before it had really started.
By this point in the pandemic, the benefits of boosters seem pretty darn clear. Boosters continue the immune system’s education on the coronavirus, upping the quantity of defensive fighters available, while expanding the breadth of variants that vaccinated bodies can snipe at. During Omicron’s winter wave, people who received a booster were less likely to be infected, hospitalized, or killed by the virus than those without a boost; older people and other high-risk populations especially benefited from dosing up again. With a menagerie of antibody-dodging subvariants now dominating the world’s stage, and more certainly on the way, boosters feel more “necessary” than ever before, says Marion Pepper, an immunologist at the University of Washington.
And yet, and yet. Eight months on from President Joe Biden’s announcement of his ambitious plan to revaccinate every eligible adult, tens of millions of eligible, vaccinated Americans—many of whom gladly signed up for their initial doses—still haven’t opted for an additional shot. Just 30 percent of the United States’ population is boosted, putting the country below most other Western nations. And with daily COVID vaccination rates only a notch above their all-time nadir and barriers to inoculation rising, the nation might be bogged down in its booster doldrums for a good while yet—leaving Americans potentially vulnerable to yet another catastrophic surge.
At face value, boosting should be one of the simplest actions a vaccinated American can take to fight COVID-19: just get one more shot. The very nature of the shots is an encore; at one point, the people who now need them “must have already decided a shot would be worthwhile,” says Van Yu, a psychiatrist at Janian Medical Care, in New York, who’s been working to immunize his city’s homeless population. For many, though, boosting is not about getting just another shot. Experts have not always sold boosters as the same slam dunk as the initial COVID-19 vaccination series; accordingly, unboosted people haven’t treated it as such. The country’s booster problem is the culmination of months of such confusion. It is also an exacerbation of the inequities that plagued the country’s initial immunization efforts. Booster uptake may present its own issues, but those only piled on the problems that vaccination efforts had encountered in all the months before.
When the first shots debuted more than a year ago, the message felt mostly uniform. “Everyone was in agreement: These vaccines are fantastic; everyone who’s eligible should get them,” says Gretchen Chapman, a behavioral scientist at Carnegie Mellon University who studies vaccine uptake. And so hundreds of millions of people did.
For boosters, experts presented nothing like that unified front. After an initial series of doses, shot-sparked defenses against hospitalization and death held up spectacularly well, but the safeguards against infection dropped far faster, making breakthroughs commonplace. Divided over what they hoped vaccines could afford—a shield against serious illness, or a blockade against as many infections as possible—experts began to argue over the need for additional shots, especially in the young and healthy. After boosters began their slow trickle out, the message to the public wasn’t that “everyone should get them,” but a sputtering of wishy-washy snippets as eligibility ballooned: Revaccinate the immunocompromised and the elderly and those with comorbidities! Let some younger, healthier people get more shots—if they’re exposed to the virus a lot—but don’t say they should! All right, everybody is allowed to boost, but only if you want to? Fine, fine, you’re all supposed to boost right now—why aren’t you boosted??
The arrival of Omicron was clarifying. The variant was so riddled with mutations that it quickly hopscotched over several of the shields raised by just one or two doses of original-recipe shots, warranting a top-off for the body’s defense. But not every expert has yet been swayed. “To date, we don’t have a variant resistant to protection against severe disease,” says Paul Offit, a pediatrician and vaccinologist at Children’s Hospital of Philadelphia who maintains that a duo of shots is enough for people who aren’t high-risk. Just a few months ago, Offit told his then-doubly-dosed son, who’s in his 20s, that he didn’t need an additional shot. (His son, Offit told me, still eventually got one.)
Punted out into the public, this messy discourse warped into confusion, consternation, and apathy. “When the scientists don’t agree, what are the rest of us supposed to do?” says Rupali Limaye, a behavioral scientist at the Johns Hopkins Bloomberg School of Public Health. In practice, it has meant that the large group of people who signed up for their first-round doses has now splintered into new booster factions. Kaleo Grant, a 23-year-old middle-school assistant sports coach in Brooklyn, told me that three of these sects exist just within his nuclear family. His father, who “took forever” to be persuaded to get his first shots, is now adamantly against boosting; his mother, who’s immunocompromised, scheduled more doses as soon as she could. Grant himself, meanwhile, is unboosted and torn. “It’s exactly what stresses me out so much—the divisiveness, even among people I know and trust,” Grant said. He was “super excited” to get his first doses last year, when the virus felt terrifying and the shots were billed as a fast track back to socializing. Both his concern over the virus and his enthusiasm for the shots have since ebbed, especially after he came down with COVID in December. Compared with the first doses, boosters feel “less urgent and maybe less necessary,” he told me, “more like a chore.”
Nor have the logistics of booster recommendations been easy to follow. In the past few months, the FDA and the CDC have issued roughly half a dozen shifts in guidance—over not only who should boost, but also when they should boost, how many boosts to get, and whether booster brands should be mixed. So maybe it’s no surprise that people have started to come to their own conclusions about just how necessary boosters are. In a January poll, run by the Kaiser Family Foundation, some eligible-but-unboosted respondents said they’d forgone an additional dose because they felt they were all set after the initial injections; others were shirking the shots because they weren’t convinced that they’d work.
The erratic narrative on vaccines writ large also hasn’t done the U.S. booster campaign any favors. When the shots were fresh out of the gate, Americans were set up to believe that they could take an initial course of doses and be done—with COVID vaccines, maybe even with the pandemic itself. But as more data emerged, it became evident that the shots’ protective powers had been oversold. Vaccines operate best in gradations, blunting and truncating the worst symptoms of disease; they never completely obliterate risk. “We failed to communicate that,” says Jessica Fishman, the director of the Message Effects Lab at the University of Pennsylvania. The arrival of boosters, then, felt to some like an admission that the first shots were a bungle—that the government and scientists had “made a mistake,” says Nina Mazar, a behavioral scientist at Boston University’s Questrom School of Business. Misinformation, including false rumors that the boosters were dangerous, or a ploy by vaccine makers to earn extra cash, then seeped into the gaps in understanding.
Even if the message on boosters had been clearer from the get-go, that wouldn’t have ensured that people got them. Vaccination rates have tended to track with risk perception, Limaye told me. But danger, at the moment, feels minimal. COVID cases have plunged from their Omicron peak, and “most people know a lot of people with it and those cases were mild,” says Noel Brewer, who studies attitudes toward vaccination at the University of North Carolina at Chapel Hill. Similar messages have been sent by pundits and world leaders, as entire countries—including the United States—have pushed the narrative that COVID is manageable, inconsequential, “endemic,” largely in retreat. SARS-CoV-2 now feels more ubiquitous, less terrifying, much more like background noise; the precautions that defined the past two years of crisis have started to disappear. The urgency of boosters simply doesn’t square with the idea that masking, surveillance, gathering restrictions, proof-of-vaccination protocols, and remote schooling and work are no longer necessary, says Neil Lewis, a behavioral scientist at Cornell University. “There’s a conflict in saying, ‘Take off your mask, but also go get another shot,’” he told me. That’s not great timing for some people who were reluctant to get even their first shots, and now feel no impetus to invest again. “We were lucky to get them to get one dose,” says Danielle Ompad, an epidemiologist at NYU.
One fact about boosting hasn’t changed. Asking people to get an additional shot means … asking people to get an additional shot, and that’s become harder than ever. As shot uptake has dropped off, vaccination sites have closed, while community outreach has pulled back. Yu, the Janian Medical Care psychiatrist, told me the teams that offered vaccines and tests at homeless shelters in his neighborhood are no longer visiting as often. And with federal funding for vaccination lapsing, Americans who don’t have insurance may need to pay out of pocket for what shots they can find. “Access is different now,” Ompad told me.
Add to that the challenges the vaccination campaign has faced from the beginning—among them employers that don’t offer paid time off for immunization, the hassles and costs of traveling for a shot, scheduling troubles for people without internet access, and the persistent paucity of medical centers in certain parts of the country, especially ones that are rural or low-income. Daniel Arias, a 23-year-old warehouse worker in Manhattan, told me he had to travel an hour each way for his first two Pfizer doses last year; “I just haven’t wanted to take the time” to get another, he said. Even if he had more flexibility in his schedule, vaccines aren’t really on his priority list. He’s caught the virus twice, and heard that “getting COVID is better for your immune system than getting the vaccine.” (Some researchers have argued that a past infection should count as a dose of vaccine, but the CDC disagrees; either way, pursuing infections is definitely not a safe or reliable way to acquire immunity.) And two years into the pandemic, “I have life to think about,” Arias said. “And at the end of the day, it’s sadly about convenience.”
Other boost-ambivalent people are worried about the shot’s side effects. Lydia Guillory, a 36-year-old marketing specialist in Ohio, has been putting off her third dose, even though she’s been eligible for it since August, because she takes immunosuppressive drugs to manage multiple sclerosis. After her second Pfizer shot last spring, she felt some of her autoimmune symptoms temporarily worsen, and her fear of experiencing another flare-up has kept her from making the leap toward another dose. “If I was not going through all this extra stuff,” Guillory told me. “I would have gotten all the shots.” (Had she received her third injection on time, she might now already be eligible for a fourth and a fifth.) “I’m just scared of another setback,” she said.
Gaps such as these could exacerbate disparities down the road. Boosts go to people who are at least a few months out from their initial doses; individuals who were vaccinated later in the rollout are reaching that point only now. Recent data from New York City, Lewis noted, show that those delayed-vaccine populations are disproportionately Black, and already more likely to be suffering some of the pandemic’s worst effects. The inequities that plagued early vaccination efforts, Lewis told me, are rearing their head again. Now that certain high-risk individuals are being asked to boost again, those first around the booster track are starting to lap those left behind. Without more attention paid to the vulnerable, boosting becomes a vicious disparity cycle: “Whatever inequities you have with first doses are likely to be amplified,” UNC’s Brewer told me. Boosting rates among Black and Hispanic people lag those of their white neighbors, according to a February Kaiser Family Foundation poll.
Issues with access, at least, have straightforward (though still difficult-to-implement) solutions. “We need to make the process easier, and more convenient,” Fishman, of UPenn, told me. Reviving and more evenly distributing community vaccination efforts could help. Stand-alone sites could take walk-in appointments; teams of volunteers could bring vials and syringes directly to the places where people live and work. Paid sick leave, subsidized transportation, or even financial incentives for vaccinations could make a big difference too. Perhaps most crucial, additional federal funding to keep vaccines free for everyone would mean shots stay within reach of some of society’s most at-risk members.
Clearer policies have a role to play too. Many workplaces, for instance, issued strict requirements for initial doses last year. But booster mandates have been sparser. With eligibility ever-changing, and the possibility of annual shots on the table, that’s logistically understandable, but it sends an implicit message, Lewis told me: “One inference people are making is If boosting was really that important, the government or my boss would be issuing a mandate.” (New Mexico’s Department of Health has, for certain workers.) Even a tweak to some terminology could help. One or two shots are needed to become “fully vaccinated” in the CDC’s eyes; boosts don’t change that, which makes the shots “sound kind of optional in a way that the primary series doesn’t,” Chapman, of Carnegie Mellon, told me.
But ultimately, bridging the booster gap will mean engaging people’s concerns: respecting individuals’ values, partnering with community messengers, and engendering trust among those who have historically had little reason to give it—the same approaches that have any chance of closing the chasm in America’s overall immunization rates. More than 20 percent of Americans remain entirely unvaccinated, according to the CDC. “I worry we’ve given up on those people,” Offit, the CHOP pediatrician, told me.
Not everyone will be nudged into a first shot, not even, necessarily, a boost. But for those who can be, it may not take much. Grant, in Brooklyn, told me he’s waiting for the right catalyst to oust him from his booster rut. Maybe it’ll take a strong endorsement from a doctor (he’s not currently seeing one). Or a massive uptick in cases (which may or may not happen soon). After speaking with me, Grant found out that his job will offer him a paid sick day after he gets a boost, which feels really “encouraging,” he said. The biggest kick in the pants, though, would come if New York made boosters a requirement to enter concerts or bars. Worries about the virus feel too distant to motivate another dose on their own, especially now that he’s had the disease and feels like he’s come out the other end. “I have very little fear of COVID now.”
The Atlantic’s COVID-19 coverage is supported by grants from the Chan Zuckerberg Initiative and the Robert Wood Johnson Foundation.